^ 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 


PRACTICAL  OBSERVATIONS 


ON 


STRANGULATED    HERNIA, 


AND  SOME  OF  THE  DISEASES 


OF  THE 


URINARY  ORGANS. 


BY   JOSEPH   PARRISH,   M.  D. 


KEY  &  BIDDLE,  23  MINOR  STREET. 
1836. 


N.\  . 


Entered  according  to  the  act  of  Congress,  in  the  year  1835,  by  Key  &  Biddle, 
in  the  Office  of  the  Clerk  of  the  District  Court,  of  the  Eastern  District  of 
Pennsylvania. 


Philadelphia: 
T.  K.  <fc  P.  G.  Collins,  Printers, 
No.  1,  Lodge  Alley. 


TO 


PHILIP  SYNG  PHYSICK,  M.  13. 

The  fathers  of  the  medical  profession  in  the  days  of  my 
pupilage  are  gone — but  thou  art  still  among  us.  Permit  one  who 
knew  thee  in  the  vigour  of  manhood,  and  listened  with  deep 
instruction  to  thy  private  lectures,  before  thy  elevation  to  a 
Professor's  Chair,  thus  publicly  to  acknowledge  the  numerous 
acts  of  kindness  and  confidence  received  at  thy  hands. 

Under  these  feelings,  can  I  do  other  than  cherish  recollec- 
tions of  the  past,  accompanied  with  a  desire,  that  now,  when 
the  shadows  of  evening  are  lengthened  out,  consolations  may 
gather  thickly  around  thee,  soothed  by  the  consciousness  of  a 
faithful  discharge  of  duty,  and  remembering  that  a  grateful  com- 
munity are  prepared  to  acknowledge  that  thy  "  lamp  has  burned 
for  the  good  of  others?" 

THE  AUTHOR. 


iV]350917 


PREFACE. 


It  would  seem  to  be  in  accordance  with  the  general 
principles,  which  ought  to  regulate  the  intercourse  of 
man  with  his  fellow  man,  that  a  reciprocity  of  informa- 
tion and  good  feeling,  should  constitute  a  common 
stock,  and  be  converted,  if  possible,  to  the  common 
good. 

For  the  accomplishment  of  this  object,  it  may  not 
be  essential  that  every  man  should  bring  in  large  ac- 
cessions of  treasure,  procured  by  the  efforts  of  unri- 
valled talents. 

Even  those  plain  and  simple  offerings,  which  are  the 
result  of  observation  and  experience  in  matters  of  fact, 
that  have  been  subjected  to  the  examination  and  ap- 
proval of  common  sense,  may  be  entitled  to  some  nook 
or  corner  in  the  great  storehouse  of  knowledge,  where 
congenial  minds  may  enter  and  examine  them. 

With  these  views  I  have  undertaken  the  task  of 
writing  a  book.  Not  without  the  forebodings  that  may 
accompany  any  common  mind,  that  has  read  the  wish 
of  a  very  ancient  writer.  Oh  that  mine  enemy  had 
written  a  book. 


VI  PREFACE. 

There  is  one  consolation,  however,  in  the  behef  that 
enemies,  if  I  have  any,  must  be  very  few,  and  so  far  as 
my  own  feelings  are  concerned,  none. 

Therefore,  with  a  firm  reliance  on  the  kindness  and 
candour  of  the  medical  profession,  and  an  earnest  de- 
sire to  be  preserved  from  doing  harm,  even  if  no  good 
is  accomplished,  I  commence  the  book. 

It  has  long  been  my  opinion,  that  men  possessing 
similar  casts  of  mind,  and  engaged  in  the  same  pro- 
fessional pursuits,  will  often  very  naturally  arrive  at 
the  same  conclusions  on  subjects  that  are  brought  be- 
fore them. 

They  may  most  honestly  believe,  and  announce  dis- 
coveries, when,  to  their  no  small  disappointment,  they 
have  to  realize  an  ancient  declaration,  "  There  is  no- 
thing new  under  the  sun." 

Angry  feehngs  have  been  excited  by  conflicting  claims, 
and  the  charge  of  plagiarism  has  been  set  up  by  one 
party,  and  denied  by  the  other. 

■  Inasmuch  as  the  meaning  of  this  w^ord,  among  men 
of  science,  is  somewhat  analogous  to  certain  terms  of 
disgrace,  which  are  used  by  persons  engaged  in  trade 
or  business,  the  writer  feels  particularly  anxious  to 
avoid  even  the  appearance  of  such  an  evil. 

In  the  acquirement  of  medical  knowledge,  throughout 
my  life,  an  aptitude  has  been  indulged  to  open  the  ave- 
nues of  the  mind  to  the  influx  of  information.  This  has 
been  derived  from  various  sources;  from  books,  espe- 
cially from  the  book  of  nature,  whose  leaves  have  been 


PREFACE.  VH 

unfolded  durii)g  many  a  midnight  hour,  at  the  bedside 
of  the  jDatient,  as  well  as  in  the  dissecting  room.  Con- 
versation with  medical  brethren  has  also  been  a  pleas- 
ing and  fruitful  source  of  knowledge. 

In  the  course  of  time,  by  reflecting  on  the  facts  and 
observations  thus  accumulated,  some  ideas  or  views 
may  have  opened  to  my  mind,  which  may  seem  to  be 
new,  that  may  be  derived  from  another  source,  and  yet 
if  called  upon  to  state  all  the  circumstances,  from  the 
first  conception  of  the  idea,  until  full  birth,  I  should  fail 
in  the  attempt. 

In  order,  then,  to  avoid  all  future  collision  and  diffi- 
culty, it  is  my  desire,  if  possible,  to  introduce  at  the 
outset,  some  quit-claim,  or  renouncing  clause,  to  new 
ideas  and  discoveries. 

Being  no  lawyer,  and  never  having  sued  a  man  in 
my  life,  there  may  be  some  difficuky  in  putting  the 
matter  in  proper  form.  Thus  much  may  serve  the  pur- 
pose, viz:  Know  all  men  of  the  medical  profession,  that 
the  author  of  this  book  will  immediately  renounce 
all  claims  to  new  ideas  and  discoveries,  as  soon  as  the 
same  may  be  made  to  appear.  He  will  not  enter  into 
htigation,  or  require  any  other  proof,  than  plain  asser- 
tion from  any  respectable  source,  on  which  he  will 
immediately  confess  judgment;  provided  the  claimant 
will  on  his  part  covenant  and  agree,  to  use  his  best 
exertions  to  render  his  own,  and  all  other  useful  in- 
formation in  the  healing  art,  as  free  as  the  air  we 
breathe. 

In  conclusion,  it  may  be  proper  to  remark,  that  my 


Vlll  PREFACE. 

medical  pupilage  was  under  the  direction  of  an  excellent 
and  beloved  preceptor,  Caspar  Wistar,  M.  D.,  who  was, 
at  that  time,  Adjunct  Professor  of  Anatomy  and  Sur- 
gery in  the  University  of  Pennsylvania.  Since  enter- 
ing on  the  arduous  duties  of  medical  life,  I  have  been 
placed  in  some  responsible  stations,  which  necessarily 
cast  me  in  the  way  of  some  experience.  In  my  earlier 
years,  I  laboured  a  long  time  among  the  poor  in  the 
Philadelphia  Dispensary.  During  one  of  our  visitations, 
I  was  appointed  by  the  Board  of  Health,  resident  phy- 
sician at  the  Yellow  Fever  Hospital,  then  situated  on 
the  eastern  bank  of  the  Schuylkill,  on  the  extensive  pre- 
mises formerly  known  as  the  "  Wigwam."  In  this  situ- 
ation, ample  opportunity  was  afforded  of  observing  this 
disease  during  life,  and  of  pursuing  dissections  after 
death. 

After  this,  in  our  Almshouse  Infirmary,  and  in  the 
Pennsylvania  Hospital,  two  of  the  largest  institutions 
of  the  kind  in  the  United  States,  it  was  my  lot  to  have 
a  considerable  share  of  laborious  business.  While  in 
private  practice,  in  the  bosom  of  a  community  wherein 
I  was  born,  and  in  a  city  where  some  of  my  ancestors, 
in  the  days  of  Penn,  lived  in  a  cave  on  the  western 
bank  of  the  Delaware,  enjoying  liberty  of  conscience, 
I  have  gratefully  to  acknowledge  a  full  portion  of  con- 
fidence and  patronage. 

Now,  while  no  claim  is  set  up  for  superior  talents,  I 
may  at  least  be  allowed  the  possession  of  a  competent 
share  of  common  sense.  Not  that  double  refined  and 
re-sublimated  sense,  in  which  some  excel;  but  that  \^  hich 


PREFACE.  IX 


is  adapted  to  practical  purposes  in  our  journey  through 
life.  To  industry,  I  must  and  ^vill  lay  claim;  it  is  ad- 
mitted to  be  a  very  humble  ingredient  in  human  cha- 
racter, and  within  the  reach  of  the  plainest  capacity. 
Yet  I  set  so  much  store  by  it,  that  should  it  be  ques- 
tioned, I  could,  without  a  blush,  call  all  Philadelphia  to 
bear  me  witness. 

I  have  long  been  engaged  in  imparting  practical 
information  to  numerous  private  pupils.  Scarcely  any 
thing  has  afforded  me  greater  pleasure,  than  to  walk 
through  the  wards  of  a  hospital,  followed  by  a  number 
of  medical  students,  and  to  observe  their  close  atten- 
tion to  clinical  instruction. 

Having  now,  for  full  thirty  years,  been  labouring  in 
my  vocation  as  a  daily  practitioner,  and  having  pre- 
served a  record  of  many  important  cases,  I  have  been 
encouraged  to  commit  some  of  the  results  of  my  expe- 
rience to  the  press,  and  thus  appear  before  the  public 
as  the  writer  of  a  book. 

I  have  selected  Strangulated  Hernia,  and  some  of 
the  Diseases  of  the  Urinary  Organs,  as  the  subjects  of 
my  first  essays. 

Should  this  work  meet  a  favourable  reception,  per- 
haps it  may  prove  the  prelude  to  a  series  of  medical 
and  surgical  observations,  to  appear  in  due  course. 

But  if  its  value  has  been  overrated,  it  may  at  least 
be  permitted  quietly  to  occupy  some  nook  or  corner  of 
the  storehouse  already  noticed,  where  it  may  repose  in 
oblivion,  along  with  its  author. 


B 


CONTENTS. 


PAOsr. 
Preface,       ---------   iv 

Introduction,       --------i 


PART  FIRST. 

ON  STRANGULATED  HERNIA. 

CHAP.  1. — Difficulties  in  the  Diagnosis  of  Hernia,  9 

Section  i.  Hernia  mistaken  for  Colic,         -         -         -  10 

Case.  Hernia  mistaken  for  Colic,       -         -         -  12 

Section  ii.  Deceptive  Symptoms,  -  -  -  -  14 
Case.  Strangulated  Hernia  with  Fecal  Discharge,  16 

Section  hi.  Diseases  resembling  Hernia,    -         -         -  18 

Enlarged  Glands,         -         -        -        .  {f}^ 

Cirsocele,                -         -         -         -         -  20 

Varicose  Vena  Saphena,       -        -         -  21 

Hydrocele,             -         -         -         -         -  ih. 

Old  Hernial  Sac,          -        -        -         -  ih, 

CHAP.  II. — Treatment  of  Hernia,            -         -         -  23 

Section  i.  On  the  means  of  Reduction  employed  before 

the  Operation,       -         -         -         -         -  ib. 

Blood-letting,          -         -         -         -         -  ih. 

Purging,        -         -         -         -         -         -  ib. 

Opiates,          ------  ib. 

Tobacco  Enema,     -         -         -         -         -  24 

fVarm  Fomentations,    -         -        -         -  25 

Taxis,    -------  /^, 


Xll  CONTENTS. 

PAGE. 

Section  ii.  On  the  Operation  for  Inguinal  and  Femoral 

Hernia. 28 

Section  hi.  On  the  propriety  of  opening  the  Hernial  , 

Sac,  -.___.     36 

Case.  Seat  of  Strangulation  within  the  Sac,       -     38 
Section  iv.  Difficulties  of  opening  the  Hernial  Sac,      -     47 
Case.  Hernial  Sac  concealed  by  a  Coagulum  of 

Blood'  -         - 48 

Case.  Distinction  between  Sac  and  Intestine  con- 
fused by  Gangrene,         -         -         -         -     52 
Case.  Hernial  Sac,  at  first, 7nistaken  for  Intestine,  53 

Case.  Inguinal  Hernia — Stricture  in  the  Sac — 

Adhesion  of  Omentum.  -         -         -     56 

Section  v.  Difficulty  of  Reduction  from  Inflammation,     57 
Case.  Strangulated   Ventro-inguinal  Hernia — 

Adherent  Intestine — Cure,    -         -         -     58 
Case.  Inguinal    Hernia — Strangulated,  dark, 

and  inflamed  Intestine,  -         -         -     62 

Section  vi.  Symptoms  of  Strangulation  after  Reduction 

by  Taxis,  -         -         -         -         -     64 

Case.  Hernia — Reduction  by  Taxis — Symptoms 
continued — Stercoraceous  Vomiting — 
Recovery,       -         -         -         -        -         -66 

Case.  Note, 71 

Section  vii.  Symptoms  of  Strangulation  after  Operation,  72 
Case.  Scrotal  Hernia — Symptoms  of  Strangula- 
tion after  Operation — Cure,  -         -     73 

CHAP.  III. — Diagnosis  of  Mortification,  -        -     80 

Section  i.  On  the  Constitutional  Evidences  of  Mortified 

Bowel,      -         -         -         -         -         -lb. 

Case.  Strangulated  Scrotal  Hernia — Gangrene 

— Death, 81 

Case.  Strangulated  Femoral  Hernia — Deceptive 

Symptoms  of  Gangrene,  -         -     85 

Case.  Strangulated  FemoralHernia — Apparently 
Mortal  Symptoms — Reduction  by  Stra- 
monium,      ------     88 


CONTENTS.  Xlll 

PAGE. 

Section  ii.  On  the  Proofs  of  Mortification  on  opening 

the  Sac, 93 

Case.  Strangulated  Hernia — Intestine  dark,  re- 
sembling Mortification,         -         -         -     95 
Case.  Femoral  Hernia — Dark  colour  of  Bowel — 

Stercoraceous  vomiting — Recovery,       -     98 

CHAP.  IV. — On    the    Management    of   Mortified 

Bowel, 103 

Case.  Ventro-inguinal  Hernia — Mortified.  Spots 

—  Testicle  involved  in  the  Tumour — Death,  106 

Case.  Note — Strangulated  Hernia — Operation 
— Consecutive  Mortification — Effusion 
—Death,  -         -         -         -         -  109 

CHAP.  V. — Artificial  Anus,-  -         -         -         -  114 

Case.  Note — Artificial  Amis  formed  by  Abscess 

— Partial  Recovery,      -        -        -        -  1 1 5 

Case.  Note — Artificial  Anus  formed  by  Abscess 

— Recovery,    -         -         -         -         -        -116 

Case.    Umbilical  Hernia — Sloughing  externally 

— Natural  Cure,  -         -         -         -  117 

Case.  Artificial  Anus — Exhaustion — Death,      -  119 
Dr.  Physick's  Operation,     -         -         -         -  121 

CHAP.  VI. — Entero  Epiplocele,       -        -        .        _  124 

Expatriated  Omentum,  _         _         _   125 

Case.  Entero-epiplocele — Expatriated  Omentum 

— Excision — Cure,        -        -        -         -  139 

Case.  Ibid, 149 

Case.  Ibid, 150 

Case.  Irreducible    Entero-epiplocele — Stercora- 
ceous Vomiting —  Operation — Death,     -  154 
Case.  Ibid,  -         -         -         -         -         -         -156 

Mortified  Omentum,         -         -         -         -  156 

Case.  Entero-epiplocele — Mortified  Omentum — 
Sloughing  of  the  Mortified  Mass — Re- 
covery, -         -         -         -         -         -159 


XIV  .  CONTENTS. 

PAGE. 

Case.  Gangrenous  Omentum  discharged  by  Jih- 

scess — Radical  Cure,      -         -         -         -  166 

Inflamed  Omentum,  -         -         -   168 

Case.    Entero-epiplocele — Omentum  Inflamed — 

Return  into  Cavity — Death,  -         -  169 

CHAP.  VII.— Concealed  Hernia,       -         -         -         -  173 

Case.  Concealed  Hernia — Strictured  Bowel  flac- 
cid—Death,  174 

Case.  Strangulated  Inguinal  Hernia — Jipparent 

Reduction  by  Taxis — Death,         -         -  176 

Case.  Strangulated  Inguinal  Hernia — Stricture 
at  Internal  Ring — Small  Tumour  ex- 
ternally— Strangulated  eight  days — 
Recovered,     -----  179 

Case.  Strangulated  Scrotal  Hernia — Jipparent 

Reduction — Recovery,  -         -         -  182 

CHAP.  VIII.— Umbilical  Hernia,     -         -        -  -  186 

Case.  Umbilical  Hernia — Mortiflcation   of  the 

Integuments — Death,    -         -         -  -  187 

Case.  Umbilical  Hernia — Radical  Cure,    -  -  190 

CHAP.  IX. — Strangulation  within  the  Abdomen,      194 

Case.    Constipation — Obstruction  produced    by 

Diseased  Omentum — Death,         -         -  195 

Case.  Strangulated  Scrotal  Hernia — Stricture 
divided — Obstruction  continued  from 
vUhesions  ivithin  the  Abdomen,  and 
Distension  of  Bowels,    -        -        -        -  197 

CHAP.  X. — Anomalous  Cases,  _         _         _         .  202 

Case.  Hernia — Sudden  Death  from  Strangula- 
tion,    -------     ib. 

Case.  Entero-epiplocele — Gradual  Approach   of 

Strangulation — Double  Sac — Death,    -  203 
Case.  Hernia — Semi- Strangulation,           -         -  205 
Case.  Mortified  Spots  producing  Death — Hyda- 
tid in  the  Sac,        -         .         -         -         .  206 
CONCLUSION.  Corollaries, 208 


CONTENTS.  XV 


PART  SECOND. 

DISEASES  OF  THE  URINARY  ORGANS. 

PAOE. 

CHAP,  I. — Retention  of  Urine,        -         .         -         -  217 

Section  i.  Deceptive  Symptoms,        _         -         -         -  218 
Case.  Enorvioiis  Distension    of  the  Bladder — 
Urine  discharged  under  the  Influence  of 
the  Will— Death,  -         -         -         -  220 

Case.  Retention  in  an  Infant — Bladder  greatly 

Distended— Death,         -         -         .         -  222 

Case.  Incontinence,  with  Retention  oj  Urine,       -  224 

Case.  Retention  from  Exhaustion  and  Nervous 

Irritation — Urine  discharged  under  the 

Influence  of  the  Will,     -         -         -         .  225 

Case.  Incontinence  and  Retention  of  Urine,         -  226 

Section  ii.  Retention  from  the  Effects  of  Cold,  -         -  227 

Cz.se..  Retention  from  Cold,         _         -         _         .  228 

Section  hi.  Retention  of  Urine  in  Fever,  -         -   229 

Case.  Note.  Retention  in  Fever,  -  -  231 

Case.  Ibid.  -------     ib. 

Case.  Retention  in  Fever — Deceptive  Symptoms,  232 
Section  iv.  Retention  from  Contusions  of  the  Body,       233 
Case.  Fracture  of  the  Pelvis  and  Ischuria,  -  225 

Case.  Fractured  Pelvis — Rupture  of  theUrethra 

— Muscular  Pouch  in  front  of  Bladder,  237 
Section  v.  Rupture  of  the  Bladder  from  Contusion  of 

the  Abdomen,  .         _         _         .  239 

C2,se.  Rupture  of  the  Bladder — Death,       -         -     ib. 
Case.   Contusion  of  the  Bladder — Lesion  of  the 

Fundus,  240 

Section  vi.  Retention  of  Urine  from  Contusion  of  the 

Perineum — Tapping  the  Bladder,      -         -  242 
Case.  Contusion  of  the  Perineum — Retention  of 

Urine  from  Effusion  of  Lymph,  -  243 


XVI  CONTENTS. 

PAGE. 

Case.  Retention  of  Urine  from  Contusion  of  the 

Perineum — Tappiiig  the  Bladder,  -  245 

Section  vii.  Retention  from  Diseased  Prostate,  -  256 

Section  VIII.  Treatment  of  Enlarged  Prostate,    -         -    , 
Case.  Note.  Enlarged  Prostate  -         -         -  261 

Case.  Ibid, '     -  264 

Passage  of  the  Catheter  in  Enlarged  Pros- 
tate, -         -         -         .  -         -  265 
Section  ix.  Retention  of  Urine  from  Pressure  on  the 

Spinal  Marrow,  -         .         .  .  269 

Case.  Note.  Retention  in  Paraplegia,         -        -  270 
Case.   Note.    Partial   Paraplegia — Retention — 

Recovery,       ------  271 

Case.  Injured  Spine — Inflammation  andUlcera- 

tion  of  the  Bladder,      -         -         -         -  272 

CHAP.  II.— On  the  Catheter,  -         -         -  276 

Directions  for  the  Use  of  the  Catheter,  -         -         -  277 
Section  i.  Difficulty  in  the  Passage  of  the  Catheter  from 

an  Effusion  of  Blood,  -  -  -  -  282 
Case.  Note.  Difficulty  from,  Blood  in  theUrethra,  283 
CdiSe,.  Difficulty  from  Blood  in  the  Bladder  cured 

by  injecting  Warm,  Water,  -         -         -  285 

CHAP.   III. — Stricture  of  the  Urethra,  -         -  288 

Section  I.  Treatment  of  Stricture,      -         -         -         _  292 
Case.  Note.  Stricture  overcome  by  Catheter  with 

a  Tapering  Extremity,  -         -         -  294 

On  the  Use  of  Caustic  in  Strictures,  -         -         -  295 
Conditions  in  which  Caustic  is  hnproper,  -  297 

Case.  Rupture  of  the  Urethra  from    the  Use  of 

Caustic,         -         -         -         -         -         -298 

Rupture  of  the  Urethra,  and  Effusion  of  Urine  into 
the  Cellular  Tissue,  -----  301 

Case.  Rupttired Urethra — Effusion  without  Gan- 
grene,   303 

Section  ii.  Fistula  in  Perineo,  -  -  .  _  305 
Case.  Note.  Fistula  in  Perineo  cured  by  Caustic,  306 
Case.  Ibid, 307 


CONTENTS.  XVU 

PACK. 

CHAP.  IV. — Tic  Doloureux  of  the  Urinary  Blad- 
der,     309 

Case.  AWe.  Tic  Boloureux  of  the  Bladder,  -  310 

Case.  Ibid, ib. 

Case.  Tic  Doloureux  of  the  Bladdei' — Death,     -  312 

CHAP,  v.— Nephritis,        -         -         -         -         -         -  314 

Caee.  Note,         -------  315 

Case.  Note.  Passage  of  a  Calculus  through  the 

Ureter 316 

Treatment  of  Nephritis, 317 

Gout  affecting  the  Kidneys,          -         -         -         -  321 
Case.  IrritableBladder  and  Urethra — Disorgan- 
ization of  the  Kidney — Death,      -        -  ib. 
Case.  Ibid, 323 

CONCLUSION, 328 

Explanation  of  the  Plates, 329 


INTRODUCTION 


It  is  not  the  intention  of  the  author  to  enter  into  an 
elaborate  anatomical  description  of  all  the  parts  con- 
cerned in  Hernia,  or  Diseases  of  the  Urinary  Organs. 
Such  descriptions  would  be  required  in  a  work  de- 
signed to  be  strictly  systematical;  but  it  would  interfere 
with  the  present  plan  of  the  writer. 

It  is  to  be  presumed  that  medical  men,  who  engage 
in  practical  surgery,  have  acquired,  by  previous  study 
and  dissection,  a  competent  knowledge  of  anatomy. 
They  ought  to  be  familiar  with  the  relative  situation 
of  parts,  especially  blood-vessels,  and  should  strive 
to  understand  those  probable  derangements  in  natu- 
ral position,  which  may  be  caused  by  distension  sud- 
denly induced,  or  by  gradual  and  morbid  changes  in 
structures.  The  situation  occupied  by  the  epigastric 
artery  in  inguinal  and  ventro-inguinal  hernia,  should  be 
distinctly  understood. 

A  chapter  is  expressly  devoted  to  directions  for  per- 
forming the  operation,  as  it  may  be  required  in  the 
several  descriptions  of  hernia;  and  a  number  of  cases 
are  given,  which  show  the  safest  plan  of  dividing  the 
stricture,  according  to  my  experience;  yet  I  feel  par- 
ticularly anxious  that  the  subject  of  femoral  hernia 
should  be  clearly  understood. 

The  exact  position   of  the  epigastric  artery  must 

ever  be  borne  in  mind,  because,  if  an  ignorant  and  in- 
1 


2-  INTRODUCTION. 

cautious  operator  attempted  to  make  an  incision 
through  the  crural  arch  upward  and  outward^  he  would 
very  probably  divide  the  epigastric  artery  near  its 
origin. 

I  have  sometimes  feared  there  may  be  too  much 
anatomical  nicety  in  the  description  of  hernia.  The 
various  layers  of  fasciae  may  tend  to  confuse  a  young 
operator.  Far  be  it  from  me,  however,  to  give  to  the 
indolent  pupil  the  slightest  pretext  for  ignorance  and 
carelessness. 

When  I  was  in  the  frequent  practice  of  demonstrat- 
ing, before  my  pupils,  the  parts  concerned  in  femo- 
ral hernia,  I  deemed  it  of  primary  importance  to  give 
to  the  learner  a  simple  and  distinct  idea  of  the  real 
seat  of  stricture,  detached  from  every  other  consi- 
deration appertaining  to  the  subject.  This  may  be 
done  by  dissecting  through  the  integuments,  and  re- 
moving from  the  groin  the  lymphatic  glands,  and  all 
other  obstructions  to  the  passage  of  the  finger  under 
the  crural  arch  into  the  abdomen. 

Let  the  index  finger  be  now  pushed  firmly  in  a  direc- 
tion towards  the  pubis — then  bend  the  first  joint  of  the 
finger  and  slowly  withdraw  it  from  the  crural  arch.  In 
doing  this,  the  pupil  will  be  sensible  of  a  sharp  or  acute 
tendinous  edge  that  he  has  hitched  upon  his  finger. 
This  is  the  real  seat  of  stricture  in  femoral  hernia.  It 
is  the  reflected  edge  of  Poupart's  ligament,  and  may 
with  great  propriety  be  called  Gimbernat's  ligament, 
because  this  surgeon  first  called  the  attention  of  the 
profession  to  this  particular  structure. 

1  can  enter  into  the  feelings  of  a  young  operator 
when  his  skill  may  be  tested  in  a  case  of  femoral  her- 
nia, perhaps  in  some  situation  remote  from  many  ad- 


INTRODUCTION.  3 

vantages  to  be  met  with  in  a  city — not  even  anatomi- 
cal references.  If  well-informed,  he  will  be  likely  to  be 
diffident;  he  may  begin  to  tax  his  memory  about  all 
the  precise  anatomical  details  connected  with  femoral 
hernia.     He  may  be  startled  at  the  fear  that  some  im- 
portant points  have  been  forgotten.  For  a  time  he  may 
be  confused.  It  is  a  moment  for  him  to  be  collected  and 
firm.     Let  him  calmly  reflect  and  simplify  his  subject. 
After  he  has,  by  safe  and  careful  dissection,  opened  the 
hernial  sac,  conformably  to  the  rules  laid  down,  what 
is  the  point  to  be  kept  steadily  in  the  eye  of  his  mind? 
Is  it  not  the  true  seat  of  stricture.     To  find  this,  let 
him  introduce  his  finger  along  the  strangulated  part, 
on  the  side  next  the  pubis,  and  then  with  the  very  tip 
of  his  finger  he  may  recognise  the  sharp  tendinous 
edge  of  Gimbernat's  ligament.     Here  fears  may  again 
assail  him.  He  may  suppose  that,  in  dividing  the  stric- 
ture, he  may  wound  the  epigastric  artery,  the  sperma- 
tic chord,  &c.     Let  him  lay  aside  his  fears,  and,  con- 
formably to  directions,  introduce  the  curved    blunt- 
pointed  bistoury  under  the  stricture,  on  the  inner  side 
of  the  strangulated  bowel  towards  the  pubis,  and  in 
the  very  gentlest  manner  divide  the  stricture  upwards. 
He  will  be  delighted  to  find  what  an  extremely  slight 
«ncision  will  be  sufficient  to  enable  him  to  pass  his 
finger  into  the  abdomen  by  the  side  of  the  strangu- 
lated part.     The  epigastric  artery  lies  on  the  outward 
side,  and  is  secured  from  harm  by  this  procedure.     I 
have  for  many  years  pursued  this  course,  generally 
inclining  the  edge  of  the  bistoury  a  little  inward,  and 
have  never  had  reason  to  suspect  that  I  ever  inflicted 
an  injury  on  the  spermatic  chord,  or  epigastric  artery. 


4  INTRODUCTION. 

It  is  hoped  the  solicitude  I  feel  on  the  subject  of  fe- 
moral hernia  will  be  excused,  even  if  some  tautology 
should  be  found  in  the  course  of  the  work.  Considerable 
complexity  is  necessarily  connected  with  this  subject, 
when  viewed  in  all  its  parts.  My  object  is  to  disentangle 
it  from  difficulties  as  far  as  possible,  and  to  fix  the  mind 
of  the  operator,  as  he  is  about  to  proceed,  upon  the 
simple  and  prominent  points  which  will  guide  him  safely 
in  his  course. 

It  is  not  in  accordance  with  the  plan  of  the  writer  to 
take  up  the  consideration  of  trusses.  Various  instru- 
ments of  this  description  are  before  the  public.  Each 
must  finally  stand  on  its  own  merits.  It  is  also  worthy 
of  remark,  that  surgeons  are  far  from  being  the  sole 
umpires  on  this  subject.  Hernia  is  a  very  common 
disease,  and  a  numerous  body  of  persons  have  had 
ample  experience  in  the  use  of  the  truss.  Many  of 
these  individuals  are  men  of  intelligence  and  reflection, 
who  feel  themselves  qualified  to  form  a  judgment  of 
their  own.  Hence  public  opinion  will  materially  regu- 
late this  subject,  independently  of  the  medical  pro- 
fession. 

On  diseases  of  the  urinary  organs,  I  would  simply  ob- 
serve, that  an  accurate  anatomical  knowledge  of  the 
parts,  both  in  a  natural  and  morbid  condition,  is  of  the 
highest  importance.  Without  this,  a  practitioner  would 
fail  in  his  efforts  to  relieve  a  patient  from  great  suf- 
fering and  danger,  at  a  moment  when  his  services 
were  imperiously  demanded.  With  it,  he  may  prove 
the  instrument  of  speedy  relief  from  one  of  the  most 
painful  conditions  to  which  the  human  frame  can  be 
subjected. 


INTRODUCTION. 


In  addition  to  anatomical  knowledge,  there  is  a  pe- 
culiar tact  in  the  use  of  the  catheter,  that  can  only  be 
acquired  by  practice;  it  is,  therefore,  highly  necessary 
that  the  student  should  avail  himself  of  every  opportu- 
nity to  introduce  the  instrument  on  the  dead  subject. 

The  position  of  the  third  lobe  of  the  prostate,  and 
the  manner  in  which  its  enlargement  produces  reten- 
tion of  urine,  and  obstructs  the  passage  of  the  catheter, 
is  worthy  of  attentive  observation.  A  preparation  of 
a  diseased  gland  in  spirits,  with  the  urethra  attached, 
answers  an  excellent  purpose  for  illustrating  this  diffi- 
culty. I  have  endeavoured  to  convey  to  the  reader  a 
clear  idea  of  this  subject,  by  referring  to  several  plates 
appended  to  this  volume.  The  drawings  were  executed 
by  an  ingenious  artist  of  this  city,  from  preparations 
now  in  my  possession. 


ERRATA. 

At  the  dash  line,  p.  57,  the  following  caption  has  been  acci- 
dentally omitted. 

SECTION  V. 

DIFFICULTIES  OF  REDUCTION,  FROM  INFLAMMATION. 

Throughout  the  work,  for  stercoracious^  read  stercoraceous. 


PART  I. 


STRANGULATED   HERNIA. 


ON 


STRANGULATED  HERNIA. 


CHAPTER  I. 


DIFFICULTIES  IN  THE  DIAGNOSIS  OF  HERNIA. 

It  is  not  an  easy  task,  in  some  cases  of  hernia,  to 
determine  the  real  nature  of  the  disease;  and  from 
want  of  attention  on  the  part  of  the  surgeon,  serious 
and  even  fatal  mistakes  have  been  made.  The  utmost 
care  is  sometimes  necessary  in  the  examination  of  the 
patient ;  and  when  all  caution  is  employed,  it  is  still 
possible  for  the  experienced  surgeon  to  be  deceived. 
Without  attempting  to  describe  every  cause  of  error 
in  the  diagnosis,  it  is  proposed,  in  the  present  chapter, 
after  premising  an  outline  of  the  common  symptoms 
of  hernia,  to  describe  such  causes  of  mistake  as  have 
been  illustrated  by  cases  occurring  under  my  own 
observation. 

The  symptoms  of  strangulated  hernia  are  as  fol- 
lows :  pain  and  tenderness  in  the  tumour,  and  extend- 

2 


10  HERNIA  MISTAKEN  FOR  COLIC. 

ing  over  the  whole  abdomen,  particularly  about  the 
umbilicus.  In  the  early  stages,  the  pain  occurs  at  short 
intervals,  gradually  becoming  more  fixed.  At  the  very 
onset  of  the  attack,  an  evacuation  from  the  bowels 
frequently  occurs ;  after  which  the  discharges  are  sus- 
pended; retching  and  vomiting  ensue,  and  the  stomach 
rejects  all  kinds  of  medicine  or  aliment.  If  these  symp- 
toms continue  for  a  short  time,  fever  is  developed ;  the 
abdomen  becomes  swollen  and  tender ;  and  the  patient 
is  thrown  into  a  state  of  distressing  and  constant 
torment,  which  is  fully  depicted  in  the  countenance. 
Among  the  most  alarming  symptoms  are,  singultus, 
tympanitic  abdomen,  and  stercoraceous  vomiting.  This 
last  mentioned  symptom  is  generally  considered  a  fatal 
one,  but  I  have  known  recoveries  after  this  event.  At 
last  there  is  a  cessation  of  all  pain;  the  patient  lies 
calm  and  comfortable,  and  he  and  his  friends  may  sup- 
pose that  the  danger  is  over.  This  idea  is  delusive. 
There  is,  indeed,  an  exemption  from  suffering,  but  the 
clammy  sweat,  the  death-like  coldness,  and  the  feeble- 
ness, or  absence  of  the  pulse,  proclaim  to  the  practi- 
tioner that  death  is  at  hand.  The  strangulation  has 
caused  inflammation,  which  has  terminated  in  mortifi- 
cation. 


SECTION  I. 

HERNIA  MISTAKEN  FOR  COLIC. 

There  are  certain  associations  connected  with  words 
that  have  an  important  bearing  on  practice — thus :  if 
I  were  called  upon  to  select  an  example,  I  should  un- 


HERNIA  MISTAKEN  FOR  COLIC.  11 

hesitatingly  say,  that  colic  ought  always  to  he  associated 
with  the  idea  of  strangulated  hernia.  I  dehver  it  as  an 
opinion  that  facts  will  sustain,  that  if  the  practice  were 
universal  to  suspect  every  case  of  colic  to  be  a  case 
of  strangulated  hernia,  many  valuable  lives  would  be 
saved. 

The  symptoms  of  cohc  and  hernia  are  so  com- 
pletely identified,  that,  in  a  majority  of  cases,  no  hu- 
man skill  can  discriminate  between  them  without  the 
most  careful  investigation.  The  attendant  symptoms 
of  an  incarcerated  bowel  differ  in  no  respect  from  those 
of  a  severe  attack  of  colic.  Thus,  violent  spasmodic 
pain  in  the  abdomen,  frequent  retching  and  vomiting, 
and  constipation  of  the  bowels,  so  often  met  with  in 
colic,  are  also  observed  in  strangulated  hernia.  The 
symptoms,  in  both  cases,  are  produced  by  the  same 
cause,  an  obstruction  in  the  course  of  the  alimentary 
tube.  In  colic,  however,  the  obstruction  is  produced 
by  a  spasmodic  contraction  of  the  muscular  fibres  of 
the  intestine,  which  usually  yields  to  a  proper  applica- 
tion of  relaxing  and  anti-spasmodic  remedies ;  while,  in 
hernia,  a  portion  of  the  bowel  is  closely  impacted  and 
retained  in  a  small  space,  and  in  an  unnatural  position, 
from  which  it  can  only  be  relieved  by  returning  the  pro- 
truded parts  to  their  proper  situation. 

Let  me,  therefore,  enforce  the  precept  so  clearly 
founded  in  reason — in  every  case  of  colic  suspect  stran- 
gulated hernia.  Painful  experience  has  taught  me, 
that  a  constant  attention  to  this  injunction  is  of  the 
utmost  importance.  I  have  frequently  been  called 
by  respectable  practitioners,  unaccustomed  to  sur- 
gery, to  consult  with  them  upon  what  they  deemed 
obstinate  cases  of  colic,  when  an  examination  of  the 


12  HERNIA  MISTAKEN  FOR  COLIC. 

groin  has  revealed  the  true  cause  of  the  symptoms  to 
be  a  strangulated  bowel!  Too  often  this  discovery- 
has  been  made  at  a  juncture  when  all  the  symptoms 
declared  that  the  prospect  of  success  from  an  opera- 
tion was  very  slight,  or  that  the  relief  of  the  patient 
was  beyond  the  reach  of  human  skill.  Numerous  cases 
of  this  description  have  fallen  under  my  notice.  I  shall 
content  myself  at  present  with  briefly  noticing  one  of 
these,  which  illustrates,  in  a  striking  manner,  the  im- 
portance of  making  the  necessary  examination ;  others 
of  a  similar  character  will  be  found  in  the  sequel. 


CASE  I. 

Hernia  mistaken  for  Colic, 

I  was  called  to  visit  the  wife  of  a  respectable  farmer, 
reported  to  be  very  ill  with  colic.  1  obtained  from  the 
attending  physician  the  following  history  of  her  case. 
Two  days  previous  to  my  visit,  while  sweeping  the 
parlour,  she  was  suddenly  seized  with  violent  pain  in 
the  abdomen,  vomiting,  and  all  the  symptoms  marking 
an  attack  of  colic.  The  family  physician,  a  man  of 
great  respectability  and  skill,  was  immediately  sent  for, 
and  steadily  pursued  the  usual  means  for  overcoming 
the  symptoms  until  the  evening  in  which  I  saw  her  in 
consultation.  The  doctor  informed  me,  that  he  had 
found  the  case  so  obstinate  that  he  had  feared  intus- 
susception. The  bowels  had  not  been  moved  from  the 
commencement  of  the  attack. 

Before  going  into  the  room,  I  stated  to  him  that  I 
suspected  strangulated  hernia,  and  requested  him  to 


HERNIA  MISTAKEN  FOR  COLIC.  13 

make  an  examination  of  the  groins.  In  a  short  time 
he  returned,  and  confirmed  my  suspicion.  A  small 
tumour  was  discovered  in  the  left  groin.  It  was  pain- 
ful to  the  touch,  and  could  scarcely  be  detected  by  the 
eye,  as  it  was  covered  with  a  considerable  quantity  of 
adipose  matter. 

The  condition  of  the  patient  was  by  this  time  very 
critical.  Her  pulse  was  feeble,  but  her  tongue  was 
moist,  and  the  abdomen  bore  pressure  very  well.  Her 
countenance  was  sunken,  and  her  complexion  of  a 
bluish  cast.  Under  these  circumstances,  it  was  thought 
advisable  to  propose  the  operation,  as  affording  the 
only  hope  of  success.  After  candidly  stating  my 
views  to  the  patient  and  her  husband,  they  at  once 
consented  to  the  operation.  An  opiate  was  adminis- 
tered by  the  mouth,  and  by  enema;  and  I  proceeded 
by  candle-light. 

After  making  the  incisions  through  the  integuments 
and  fasciae,  I  exposed  a  small  femoral  hernia.  The 
sac  was  carefully  opened,  and  a  small  quantity  of  fluid 
escaped,  having  a  slight  cadaverous  smell.  A  portion 
of  the  intestine  was  of  an  ash  colour,  and  flaccid — 
a  state  of  things  which  I  consider  highly  unfavourable. 
The  finger  was  introduced  to  the  point  of  stricture, 
which  was  readily  divided. 

Directly  after  the  operation,  the  pulse  was  very 
feeble,  and  the  skin  cool;  but  after  the  patient  was 
placed  in  bed,  her  system  re-acted,  and  she  expressed 
herself  much  more  comfortable.  I  left  her  late  in  the 
evening. 

Next  morning  I  received  a  letter  from  her  physi- 
cian, informing  me  that  she  died  at  about  two  o'clock, 
A.M. 


14  DECEPTIVE  SYMPTOMS. 

I  would  here  impress  upon  the  surgeon  the  import- 
ance of  making  a  thorough  and  minute  examination  of 
the  different  points  at  which  the  protrusion  in  hernia 
is  hkely  to  occur,  and  not  to  be  content  with  a  super- 
ficial view.  For,  though  he  will  generally  be  able  to 
decide  upon  the  case  without  difficulty,  yet  circum- 
stances do  sometimes  occur  which  tend  to  obscure  the 
tumour,  and  may  lead  to  uncertainty.  I  shall  mention 
a  case  in  the  sequel  in  which  I  was  myself  deceived, 
and  I  have  no  doubt  others  have  been  similarly  situated. 

Nor  should  the  surgeon  rely  simply  on  the  state- 
ment of  the  patient,  without  examining  for  himself. 
The  tumour  may  be  so  small  as  to  escape  the  atten- 
tion of  the  individual  affected ;  it  may  have  occurred 
very  recently,  and  may  not  have  been  noticed ;  or,  as 
sometimes  happens  in  the  case  of  young  and  modest 
females,  its  existence  may  be  concealed  from  motives 
of  false  delicacy. 

On  the  whole,  in  every  suspicious  case,  it  is  the  safer 
plan  for  the  surgeon  to  make  for  himself  a  careful  ex- 
amination. No  harm  can  result  from  pursuing  this 
course,  while  an  observance  of  it,  I  am  convinced, 
would  tend  very  much  to  the  safety  and  profit  of  the 
patient,  and  to  the  credit  and  usefulness  of  the  medical 
attendant. 


SECTION  II. 

DECEPTIVE  SYMPTOMS. 

When  the  bowel  is  suddenly  subjected  to  strangula- 
tion, the  'pinch  received  by  this  delicate  part  must 


DECEPTIVE  SYMPTOMS.  15 

naturally  excite,  for  a  moment,  an  increase  of  peri- 
staltic action,  which,  operating  below  the  stricture, 
may  prove  sufficient  to  expel  the  fecal  matter,  and 
thus  a  free  stool  may  be  one  of  the  first  evidences  of 
strangulated  bowel.  This  very  symptom  is  so  en- 
tirely the  reverse  of  the  common  opinion  entertained 
of  incarcerated  intestine,  that  even  a  practitioner,  un- 
accustomed to  the  disease,  might  readily  conclude 
that  there  could  not  exist  any  mechanical  obstruction 
to  the  passage  through  the  alimentary  canal.  Under 
this  impression  days  may  elapse,  and  the  proper  period 
for  successful  operation  may  pass  over,  before  he 
discovers  his  mistake.  Other  causes  may  operate  to 
keep  up  this  deception,  until  mortification  and  death 
reveal  the  truth. 

Some  years  ago,  I  was  called,  by  my  departed 
friend  Dr.  Knight,  to  visit  an  aged  widow  in  Keys' 
alley.  The  symptoms  of  strangulation  were  per- 
fectly plain;  the  operation  was  proposed,  and  con- 
sented to  by  the  patient ;  and  the  hour  fixed  for  its 
performance ;  but,  on  our  meeting  again  for  the  pur- 
pose, she  had  changed  her  mind,  and  would  not  sub- 
mit. The  patient  and  her  female  attendants  insisted 
upon  it  that  her  bowels  were  opened,  and  that  she 
passed  flatus  very  freely.  In  a  few  days  the  patient 
died.  I  examined  the  body  after  death,  in  company 
with  Dr.  Knight,  and  found  a  portion  of  bowel  stran- 
gulated and  mortified. 

Another  instance,  somewhat  similar  to  this,  occurred 
in  the  Pennsylvania  Hospital.  A  patient  was  brought 
in,  and  reported  to  have  had  discharges  of  fecal  mat- 
ter and  flatus ;  yet,  on  operating,  a  portion  of  bowel 
was  found  incarcerated  and  sphacelated.    The  patient 


16 


DECEPTIVE  SYMPTOMS. 


died.  Several  instances,  strongly  confirmatory  of  the 
views  here  advanced,  will  be  found  in  the  succeeding 
pages ;  and  the  details  of  one  case  of  this  kind  will 
be  added  at  the  close  of  this  section. 

I  am  inclined  to  believe  that  many  of  these  decep- 
tive symptoms  depend  upon  the  frequent  use  of  injec- 
tions, especially  when  administered  on  the  old  fashioned 
plan  of  pipe  and  bag.  In  this  way  it  often  happens 
that  a  considerable  portion  of  air  is  injected  into  the 
bowels,  and,  when  returned,  may  convey  the  idea  of 
an  open  passage  from  the  stomach  to  the  anus.  The 
enema  may  also  bring  away  a  sufficient  portion  of  fecal 
matter  to  colour  the  injected  fluid,  which,  without  close 
inspection,  may  pass  for  a  real  stool. 


CASE  11. 

Strangulated  Hernia  withfcBcal  discharge. 

9th  mo.  20th,  1819. — I  was  called  this  morning  to 
the  Pennsylvania  Hospital,  to  consult  with  my  col- 
leagues, Drs.  Hewson  and  Hartshorne,  on  the  case 
of  an  old  coloured  man  affected  with  strangulated 
inguinal  hernia. 

The  tumour  was  distinct,  and  the  symptoms  of  stran- 
gulation sufficiently  marked,  though  less  severe,  than 
in  ordinary  cases.  As  his  stomach  was  retentive,  we 
agreed  to  try  the  effect  of  purgatives  for  a  few  hours. 
We  directed  jalap  and  cream  of  tartar  to  be  adminis- 
tered frequently,  and  in  divided  portions. 

In  the  afternoon  we  met  again.  The  house-sur- 
geon reported  that  he  had  taken  siss.  of  jalap  mixed 


DECEPTIVE  SYMPTOMS.  17 

with  cream  of  tartar,  and  had  retained  it  on  his  sto- 
mach, hut  without  any  effect  upon  his  bowels.  The 
tumour  was  still  firm,  and  the  symptoms  well  marked. 
We  concluded  to  advise  the  operation  immediately 
after  making  the  necessary  preparations;  and,  as  we 
were  about  to  have  the  patient  carried  to  the  operat- 
ing room,  he  had  a  copious  evacuation  from  the  bowels, 
accompanied  with  a  discharge  of  flatus.  This  cir- 
cumstance induced  us  to  delay  the  operation,  suppos- 
ing that  the  stricture  had  at  least  partially  yielded. 
We  then  left  the  patient,  to  meet  again  on  the  follow- 
ing morning. 

21 5/. — On  visiting  the  patient  this  morning,  we  found 
that  his  symptoms  were  still  more  alarming.  In  addi- 
tion to  pain  and  constipation,  he  was  affected  with 
vomiting  and  singultus.  The  tumour  was  firm,  and 
no  discharge  had  followed  that  which  occurred  at  our 
last  visit. 

We  at  once  concluded  to  operate.  Dr.  Hewson 
performed  the  operation.  On  laying  open  the  sac,  a 
portion  of  intestine  was  found  in  a  state  of  high  in- 
flammation, and  coated  with  a  thick  layer  of  coagulated 
lymph.  We  concluded  to  detach  the  lymph  before 
returning  the  parts;  which  was  readily  effected  by 
means  of  the  handle  of  the  scalpel.  The  intestine 
was  very  much  thickened  by  inflammation;  so  that 
Dr.  H.  was  obliged  to  dilate  the  ring  freely,  in  order 
to  accomplish  the  reduction.  The  patient  bore  the 
operation  very  well,  and  recovered  completely  under 
Dr.  Hewson's  care. 


18  DISEASES  RESEMBLING  HERNIA. 


SECTION  III. 


DISEASES  RESEMBLING  HERNIA. 


There  are  several  diseases  occurring  in  the  parts  in 
which  hernial  tumours  are  generally  developed,  which 
may,  by  the  inattentive  observer,  be  mistaken  for  it ; 
and  a  practice  may  be  instituted,  in  consequence,  which 
may  lead  to  serious  results.  In  a  large  proportion  of 
cases,  the  mere  examination  of  the  external  tumour 
will  be  sufficient  to  decide  the  nature  of  the  complaint. 
In  small  hernia,  however,  and  especially  when  the 
tumour  is  obscured  by  fat,  a  more  accurate  examina- 
tion is  often  necessary ;  but  little  doubt  can  be  enter- 
tained, even  under  these  circumstances,  when  the  his- 
tory of  the  case  is  minutely  investigated.  Still,  as 
mistakes  in  the  diagnosis  have  sometimes  occurred,  it 
may  be  proper  to  notice  some  of  the  diseases  with 
which  hernia  is  confounded. 

One  of  the  most  common  sources  of  error  arises 
from  an  enlarged  state  of  the  inguinal  glands,  forming 
a  tumour  resembling  in  size  and  shape  a  hernia.  In- 
stances are  on  record  of  hernial  tumours  being  treated 
as  inflamed  glands  until  the  period  for  successful  treat- 
ment has  passed  by.  Cooper  and  Petit  relate  several 
cases  of  this  description  which  fell  under  their  notice, 
in  which  the  error  proved  fatal  to  the  patient;  and 
Lawrence  tells  us,  that  he  knew  a  hospital  surgeon  of 
considerable  eminence,  who  allowed  a  patient  to  die  of 
strangulated  hernia,  under  a  belief  that  the  tumour  in 


DISEASES  RESEMBLING  HERNIA.  19 

the  groin  was  a  chain  of  inflamed  glands.  A  post 
mortem  examination  revealed  the  true  cause  of  death. 

I  have  never  met  with  a  case  in  which  this  error 
proved  fatal,  though  I  have  known  inflamed  glands  to 
be  mistaken  for  hernia.  I  was  called,  late  one  even- 
ing, to  visit  a  patient,  in  consultation  with  two  respect- 
able physicians.  The  messenger  was  very  urgent,  and 
requested  that  I  would  come  prepared  to  operate. 

On  arriving  at  the  place,  1  found  a  man  who  ap- 
peared to  be  in  great  distress,  complaining  of  violent 
pain  in  his  abdomen,  &c.  I  soon  discovered,  how- 
ever, that  his  violent  iflness  was  altogether  a  pretence, 
and  that  the  tumour  in  the  groin  was  a  venereal  bubo  ! 
He  had  been  attempting  to  deceive  his  medical  attend- 
ants, for  the  purpose  of  concealing  from  his  friends 
his  real  situation,  and  had  completely  succeeded. 

Another  very  similar  case  occurred  to  me.  I  was 
called,  by  a  respectable  medical  practitioner,  to  see  a 
patient  with  whom  he  had  been  labouring  for  a  consi- 
derable time,  to  reduce  a  rupture.  He  had  been  freely 
bled,  and  the  taxis  had  been  diligently  tried,  and  the 
physician  now  called  on  me  to  operate.  On  examining 
the  tumour,  I  immediately  recognised  a  venereal  bubo. 
On  mentioning  the  fact  to  the  patient,  he  promptly  and 
positively  denied  it.  I  then  pulled  back  the  prepuce 
and  exposed  a  large  chancre  on  the  glans  penis.  This 
terminated  the  consultation. 

The  following  note  from  my  case-book  presents  an 
unusual  complication  of  circumstances  leading  to  de- 
ception. 

Sth.  mo.  1822. — In  a  late  case  at  the  hospital,  which 
I  saw  in  consultation  with  Drs.  Price  and  Hewson,  we 
supposed  the  patient  to  labour  under  a  strangulated 


20  DISEASES  RESEMBLmb  HERNIA. 

hernia.  He  represented,  that  he  had  been  subject  to 
hernia  for  some  years,  and  had  been  in  the  habit  of 
wearing  a  truss ;  that  he  had  lost  his  truss  at  sea,  and, 
since  that  accident,  his  rupture  had  descended.  He 
was  at  this  time  labouring  under  an  attack  of  gonor- 
rhoea, with  considerable  swelling  of  the  scrotum  and 
surrounding  glands.  He  had  fever,  and  his  bowels 
were  moved  by  medicine.  The  tumefaction  in  the 
groin  was  very  considerable,  and  resembled  very  much 
the  tumour  of  an  omental  hernia.  He  was  directed 
bleeding  from  the  arm;  leeches  to  the  abdominal  ring ; 
the  recumbent  posture,  with  the  hips  elevated ;  and  we 
determined  to  watch  the  case  and  consult  again  if 
necessary.  In  a  short  time  it  was  discovered,  that 
the  tumour  resembling  hernia  arose  from  an  abscess 
which  had  formed  in  the  groin ;  and  that  the  real  old 
hernia  was  on  the  opposite  side,  and  had  not  been 
altered  from  its  usual  appearance. 

A  frequent  source  of  error  in  the  diagnosis  of  hernia 
arises  from  the  appearances  presented  by  the  spermatic 
veins  when  in  an  enlarged  or  varicose  condition.  This 
disease,  called  circocele,  is  very  common,  particularly 
among  young  men;  and  is  frequently  mistaken  for 
hernia.  I  have  been  called  upon  very  often  by  indivi- 
duals affected  with  circocele  who  have  worn  trusses 
for  a  considerable  time,  under  an  impression  that  they 
laboured  under  hernia;  and,  not  unfrequently,  their 
fears  have  been  confirmed  by  their  medical  advisers. 

In  cases  of  doubt,  the  point  may  be  readily  settled 
by  requesting  the  patient  to  lie  down ;  when,  in  the 
circocele,  the  tumour  immediately  recedes :  moreover, 
it  communicates  to  the  touch  a  peculiar  sensation ;  so 
that  when  grasped  between  the  thumb  and  finger,  it 


DISEASES  RESEMBLING  HERNIA.  21 

resembles  a  bundle  of  worms  entwined  together  be- 
neath the  integuments.  To  render  the  case  still  more 
plain,  the  abdominal  ring  should  be  carefully  examined. 

A  case  is  mentioned  by  Petit,  in  which  the  saphena 
vein  was  so  much  distended  as  to  be  mistaken  for  a 
femoral  hernia,  and  under  this  impression,  a  truss  was 
actually  applied  by  a  physician.  The  tumour,  in  this 
case,  was  reduced  by  pressure,  was  increased  by  cough- 
ing, was  produced  by  the  erect  position,  and  disap- 
peared in  the  recumbent  posture. 

Hydrocele  of  the  tunica  vaginalis  testis,  or  of  the 
spermatic  cord,  has  occasionally  been  mistaken  for 
hernia ;  but  the  slow  progress  of  the  tumour,  and  the 
transmission  of  light  through  the  part,  should  render 
the  distinction  certain. 

I  have  seen  one  case,  in  which  a  thickened  hernial 
sac  produced  a  tumour,  which  was  a  cause  of  decep- 
tion. The  patient  was  an  old  coloured  man  who, 
some  years  ago,  was  brought  into  the  alms-house  in- 
firmary, labouring,  as  was  supposed,  under  strangulated 
hernia.  He  was  affected  with  vomiting,  severe  pain 
in  the  abdominal  region,  tympanitic  abdomen,  tender- 
ness on  pressure,  and  obstinate  constipation.  It  was 
ascertained  that  he  had  been  affected  with  rupture  for 
many  years ;  and  that  strangulation  had  taken  place 
occasionally.  There  was  a  distinct  tumour  in  the 
groin. 

Under  these  circumstances,  a  consultation  of  the 
surgeons  of  the  institution  was  called  to  decide  on  the 
propriety  of  an  operation,  and  the  students  were  col- 
lected to  witness  it.  I  recognised  in  the  man  an  old 
Dispensary  patient,  whom  I  had  frequently  attended ; 
and  recollected  that,  on  one  occasion,  I  had  seen  him 


22  DISEASES  RESEMBLING  HERNIA. 

in  an  attack  of  strangulated  hernia,  and  had  reduced 
the  parts  by  taxis.  On  a  close  examination  of  the 
tumour,  we  were  all  struck  with  its  flabby  and  inelastic 
feel,  differing  very  much  from  the  firm  and  elastic  feel 
of  a  strangulated  hernia.  As  the  case  was  obscure, 
it  was  concluded  to  postpone  the  operation  until  fur- 
ther light  could  be  thrown  on  it.  The  next  day,  the 
friends  of  the  patient  removed  him  from  the  infirmary, 
and  Dr.  Hewson  saw  him.  The  symptoms  continued 
unabated,  and  the  patient  died. 

Dr.  Hewson  obtained  permission  to  examine  the 
body,  and  found  that  the  tumour  was  caused  by  a 
hernial  sac  very  much  thickened  by  chronic  inflamma- 
tion. This  old  sac  had  been  affected  with  recent  and 
violent  inflammation,  which  had  extended  to  the  peri- 
toneum, and  involved  it  also  in  general  high  inflamma- 
tion. 


CHAPTER  II. 


TREATMENT  OF  HERNIA. 


SECTION  I. 


ON  THE  MEANS  OF  REDUCTION   EMPLOYED   BEFORE  THE 

OPERATION. 

Various  remedies  have  been  proposed  by  surgeons 
for  relieving  a  strangulated  bowel,  before  proceeding 
to  an  operation.  The  object  of  all  these  is  to  bring 
on  a  general  relaxation  of  the  system,  and  quiet  the 
irritability  and  pain  of  the  patient.  Some  such  mea- 
sures should  certainly  be  employed,  and  among  them, 
hlood-letting  holds  a  conspicuous  rank.  I  have  occa- 
sionally seen  cases  of  strangulation  in  which  free 
bleeding  brought  on  relaxation,  and  the  protruded 
bowel  was  happily  returned. 

Purging  has  been  proposed ;  but  this  practice,  where 
the  stricture  is  recent,  rather  tends  to  aggravate  than 
to  relieve  the  symptoms.  In  cases  of  old  and  irredu- 
cible hernia),  the  purging  plan  may  be  useful. 
•  Opiates  arc  valuable  remedies  when  administered 
under  proper  circumstances.  Sometimes,  after  the 
free  use  of  the  lancet,  an  opiate  has  been  adminis- 
tered, the  stricture  has  given  way,  and  the  bowel  has 


24  MEANS  OP   REDUCTION 

been  returned,  with  little  difficulty.     The  warm  bath 
also  is  entitled  to  a  trial. 

Among  the  most  prominent  means  for  producing 
relaxation,  and  one  which  is  very  often  employed,  is 
the  tobacco  enema.  This  remedy  is,  I  believe,  recom- 
mended by  most  surgeons,  before  proceeding  to  an 
operation.  Such  a  general  recommendation  I  consider 
of  doubtful  propriety,  particularly  where  the  system 
has  been  reduced  by  previous  depletion.  In  cases 
in  which  there  may  be  a  deficiency  of  constitutional 
vigour,  I  should  be  very  cautious  about  proposing  it ; 
believing  that,  as  a  general  rule,  the  depressing  effects 
which  it  produces  on  some  constitutions  are  more  to 
be  dreaded  than  even  the  operation  itself  when  per- 
formed by  a  skilful  hand.  This  opinion  has  been 
formed  from  some  experience.  Nor  am  I  alone  in 
my  fears : — the  distinguished  Hey,  of  Leeds — a  man 
whose  opinions  are  entitled  to  the  greatest  respect — 
says  that  an  operation  should  never  be  performed  on 
a  patient  while  labouring  under  the  effects  of  a  tobacco 
enema.  He  even  mentions  the  case  of  a  patient  who 
died  soon  after  his  removal  from  the  operating  table, 
under  the  circumstances  mentioned. 

I  was  once  concerned,  with  several  other  surgeons, 
in  a  case  where  we  were  all  very  much  alarmed  at 
the  eflfects  of  a  tobacco  enema.  The  patient  was 
suffering  from  a  disease  of  the  urinary  organs;  and 
soon  after  the  injection  was  administered,  he  fell  into 
a  state  of  the  most  dreadful  prostration,  from  which 
he  was  aroused  with  the  greatest  difficulty,  by  appro- 
priate treatment. 

I  understand  that  a  formula  directing  two  drachms 
of  tobacco  to  the  pint  of  water  is  used  in  one  of  the 


EMPLOYED  BEFORE  THE  OPERATION.  25 

London  hospitals.  This  I  should  consider  very  dan- 
gerous. One  drachm,  or  even  half  a  drachm,  I  con- 
sider sufficiently  strong ;  and  even  then  advise  its  in- 
troduction gradatim,  carefully  watching  its  effects. 

Warm  fomentations  to  the  tumour  have  been  pro- 
posed by  some  surgeons :  these,  however,  by  causing 
increased  activity  and  fulness  of  circulation,  rather 
tend  to  aggravate,  than  to  relieve  the  symptoms.  Cold 
applications  are  now  generally  employed ;  and  are,  as 
a  general  rule,  much  to  be  preferred.  A  bladder  filled 
with  ice  and  applied  to  the  tumour,  is  a  common  prac- 
tice. I  recollect  a  case  in  which,  after  a  free  bleedings 
this  plan  was  resorted  to,  and  the  bowel  speedily  re- 
turned by  its  own  efforts. 

Much  has  been  said  and  written  about  the  taxis,  and 
much  may  be  properly  said,  for  the  subject  is  an  in- 
teresting one.  For  my  own  part,  I  am  inclined  to  con- 
sider taxis  in  hernia,  and  crepitus  in  fracture,  as  two 
unhappy  words.  They  are  so  intimately  associated 
with  the  idea  of  mechanical  force,  that  the  poor  pa- 
tient may  be  subjected  to  an  increase  of  pain  and  dan- 
ger by  their  application  to  practice.  Thus  I  have  seen 
a  young  house-surgeon,  with  more  zeal  than  know- 
ledge, work  away  upon  a  lower  extremity  almost  with 
the  force  that  would  be  employed  in  mauling  rails; 
and,  while  twisting  and  pulling  the  limbs  of  the  poor 
patient,  his  ear  was  at  certain  points  so  adjusted,  as 
to  catch  the  sound  of  a  crepitus,  to  decide  the  ques- 
tion of  fracture !  If  a  practice  of  this  kind  was  ob- 
viously improper,  and  calculated  to  increase  the  pain 
and  inflammation  of  the  injured  parts,  how  much  more 
improper  must  it  be  when  applied  to  a  strangulated 
and  inflamed  bowel !     Thus,  when  I  was  a  student,  I 

4 


26  MEANS  OF  REDUCTION 

once  saw  a  medical  practitioner  take  off  his  coat,  and 
fall  to  work  at  the  taxis  in  a  case  of  strangulated  her- 
nia,  with  all  the  force  and  industry  that  would  be  re- 
quired for  some  laborious  mechanical  operation.  He 
pushed  and  dug  at  the  poor  patient  at  a  terrible  rate, 
and  all  without  success ! 

Now  let  common  sense  speak  on  this  subject.  What 
can  be  more  irrational  than  to  apply  force  to  a  tender 
bowel  already  in  a  state  of  inflammation  ?  What  more 
likely  plan  to  hurry  on  the  bowel  to  mortification,  and 
the  patient  to  death?  I  lay  it  down  as  a  principle 
that  all  force  in  such  a  case  is  improper — arte  non  vi 
should  be  the  maxim  of  the  surgeon. 

There  is  another  view  to  which  this  subject  is  enti- 
tled. Let  not  the  young  surgeon  despise  the  innate 
capacity  which  even  the  ignorant  possess,  of  adapting 
means  to  their  own  relief  which  are  the  result  of  their 
own  experience.  I  have  often  met  with  patients  who 
were  expert  in  performing  the  taxis  for  themselves ; 
and  for  many  years  past,  I  have  not  permitted  profes- 
sional pride  to  prevent  me  from  requesting  patients  to 
try  their  own  skill  in  the  reduction  of  the  rupture.  To 
illustrate  these  remarks,  I  will  state  a  case.  An  igno- 
rant  servant-woman  was  violently  attacked  with  a  small 
strangulated  femoral  hernia.  When  the  patient  was 
in  a  state  of  relaxation,  and  at  a  favourable  moment 
for  the  trial,  I  requested  her  to  "  try  to  put  it  up ;"  and  I 
carefully  watched  her  movements.  She  laid  upon  her 
side,  inclined  the  trunk  forward,  drew  up  her  knees, 
and  flexed  the  thighs  upon  the  pelvis;  thus  causing 
complete  relaxation  of  the  abdominal  muscles  and 
fasciae,  and,  by  her  own  efforts,  reduced  the  incarce- 
rated bowel. 


EMPLOYED  BEFORE  THE  OPERATION.  27 

An  old  anatomist  of  a  facetious  turn,  and  fond  of 
his  stomach,  used  to  say,  that  after  taking  so  much 
pains  to  inform  himself  of  the  structure  of  the  parts 
concerned  in  deglutition,  he  could  not  swallow  better 
than  other  men ; — and  the  oldest  and  most  experienced 
surgeons  must  admit  that,  in  some  cases,  even  the  igno- 
rant compete  with  them  successfully  in  performing  the 
operation  of  the  taxis ; — but  let  not  this  anecdote  be 
construed  by  the  indolent  into  a  plea  for  inattention 
and  ignorance. 

The  celebrated  Desault  was  so  fully  convinced  of 
the  great  danger  of  immoderate  efforts  in  applying 
taxis,  that  he  condemns  it  in  almost  every  instance. 
In  his  opinion,  the  bruising  and  other  injuries  inflicted 
on  the  bowel  by  the  surgeon,  in  such  attempts,  may 
render  the  state  of  the  patient  as  critical  after  the 
reduction,  when  accomplished^  as  it  is  before  the  reduc- 
tion. Desault  has  witnessed  many  cases  that  tend  to 
show  a  great  difference  in  the  mortality  after  operat- 
ing, in  favour  of  those  operations  which  have  been 
performed  on  patients  who  have  not  been  previously 
subjected  to  the  taxis.  "  You  may  always  hope  for  suc- 
cess," he  says,  "  in  a  hernia  which  has  not  been  touched 
before  operating."* 

He  often  succeeded  completely  in  operating  upon 
patients  who  had  not  been  tampered  with,  even  after 
the  strangulation  had  continued  four  or  five  days ;  but 
when  strong  efforts  had  been  made  to  reduce  the  her- 
nial  contents,  he  almost  constantly  met  with  a  fatal 
result. 

*  Ouvres  Chirurgicales  par  Bichat,  p.  3.34. 


28  OPERATIONS  FOR   INGUINAL 


SECTION  11. 

ON  THE  OPERATIONS  FOR  INGUINAL  AND  FEMORAL  HERNIA. 

After  having  employed  without  success  the  usual 
means  for  the  reduction  of  a  hernia,  we  should  pro- 
ceed to  the  operation ;  and  here  it  may  be  remarked, 
that  much  danger  often  arises  from  improper  delay. 
Physicians,  it  is  to  be  feared,  are  too  apt  to  rely  on 
subordinate  means  until  at  last  they  are  obliged  to 
resort  to  the  knife  when  too  late.  From  six  to  twelve, 
or  at  most  twenty-four  hours,  according  to  the  urgency 
of  the  symptoms,  affords  sufficient  time  to  employ  the 
ordinary  means  for  reduction. 

The  longer  I  live,  and  the  more  I  see  of  strangulated 
hernia,  the  more  firmly  I  am  convinced  of  the  correct- 
ness of  the  observation  of  the  distinguished  Hey,  given 
to  us  as  the  result  of  a  long  life  of  experience.  "  I  have 
often  had  occasion  to  regret,"  says  he,  "  that  I  per- 
formed the  operation  too  late,  but  never  that  I  perform- 
ed it  too  early.'''' 

When  the  operation  is  concluded  upon,  it  is  my 
uniform  practice,  as  in  most  other  operations,  to  give 
an  opiate,  either  by  the  mouth  or  rectum.  I  am  aware 
that  the  general  application  of  this  practice  is  objected 
to  by  some  men  of  high  character : — it  is  said  that 
opium  is  a  stimulant,  and  tends  to  excite  the  system, 
produces  fever,  &c.  This  fear,  I  believe,  is  grounded 
in  theory  rather  than  in  practice.  I  give  opium  to 
prevent  fever,  and  believe  the  practice  not  only  to  be 
successful,  but  rational.     The  calming  influence  gene- 


AND  FEMORAL  HERNIA.  29 

rally  produced  by  this  article  tends  to  lessen  the  pain 
of  surgical  operations,  and  the  shock  which  they  occa- 
sion ;  and  hence,  it  assists  in  mitigating  one  of  the  great 
sources  of  subsequent  reaction  and  fever.  I  have  never 
seen  any  other  effect  produced  by  it,  though  I  have 
employed  it  very  generally  in  my  surgical  practice. 

Having  prepared  the  necessary  instruments,  the  pa- 
tient should  be  placed  on  a  convenient  table,  and  the 
parts  over  and  around  the  tumour  are  to  be  shaved. 
Supposing  the  hernia  to  be  scrotal,  we  commence  the 
incision  a  small  distance  above  the  external  abdominal 
ring,  and  extend  it  downward  over  the  tumour  nearly 
to  its  termination.  In  doing  this,  some  small  branches 
of  the  external  pudic  artery  are  divided,  which,  though 
of  no  great  consequence,  should  be  secured  by  liga- 
tures, to  prevent  the  blood  from  confusing  the  parts  as 
the  operation  advances. 

In  the  first  incision,  it  is  my  practice  to  pinch  a  fold 
of  the  skin,  covering  the  tumour  with  the  fingers  of  the 
left  hand,  and  to  request  an  assistant  to  do  the  same 
on  the  opposite  side.  The  sharp  pointed  bistoury, 
with  its  back  towards  the  tumour,  is  passed  through  the 
elevated  portion  of  skin,  and  the  cut  made  upwards : 
in  this  way  a  large  incision  is  speedily  eflfected,  with- 
out the  least  risk  to  the  parts  below.  Care  should  be 
taken  to  have  the  wound  of  sufficient  extent  to  prevent 
subsequent  embarrassment. 

After  the  first  incision  through  the  skin,  a  coat  of 
dense  cellular  membrane  presents  itself,  which  must  be 
carefully  divided.  This  is  easily  done  by  cutting  with 
a  sharp  pointed  bistoury  upon  a  small  silver  director. 
This  latter  instrument  seems  to  be  despised  by  some 
modern  surgeons,  who  tell  us  we  should  depend  upon 


30  OPERATIONS  FOR  INGUINAL 

our  powers  of  skilful  dissection  with  the  scalpel.  Their 
advice  may  tend  to  foster  professional  pride,  but  it  is 
certainly  not  judicious  if  safety  and  expedition  are 
desirable.  The  director  is  passed  under  a  layer  of 
this  cellular  fascia,  and  a  free  incision  is  made  upon 
it.  By  adopting  this  plan,  all  risk  of  wounding  the 
bowel  is  prevented,  and  the  cellular  substance  can  be 
divided  much  more  rapidly  than  by  using  the  scalpel, 
especially  in  femoral  hernia. 

Much  has  been  said  of  the  different  layers  of  fascia 
to  be  divided  before  coming  to  the  sac :  these  are  de- 
monstrated with  the  greatest  minuteness  and  accuracy, 
and  are  well  calculated,  from  their  apparent  complexity, 
to  alarm  the  young  practitioner.  This  extreme  ana- 
tomical nicety  appears  to  me  unnecessary ; — no  matter 
how  many  layers  are  presented,  they  must  be  divided 
until  we  arrive  at  the  tendon  of  the  external  oblique 
muscle,  and  expose  the  sac. 

Having  reached  the  sac,  the  most  important  part  of 
the  operation  commences.  On  opening  it,  the  surgeon 
is  often  assailed  by  difficulties  which  I  shall  endeavour 
to  expose  in  detail  hereafter.  We  will  suppose,  how- 
ever, that  the  case  is  a  plain  one.  The  sac  will  be 
found  to  contain  fluid,  sometimes  in  considerable  quan- 
tity ;  and  a  distinct  point  of  fluctuation  presents  itself, 
as  in  an  abscess.  This  spot  should  be  selected  for  the 
opening. 

The  opening  should  be  made  with  caution.  The 
prominent  point  of  the  sac  should  be  ^^mcAec?  up  with 
a  small  pair  of  forceps,  and  a  sharp  thumb  lancet  or 
scalpel  applied,  and  carried  obliquely  upward.  The 
sac  being  opened,  the  fluid  will  at  once  escape.  If  it 
be  of  a  bloody  colour,  it  may  alarm  the  young  prac- 


AND  FEMORAL  HERNIA.  31 

titioner,  but  this  is  neither  uncommon  nor  unfavourable. 
Having  made  the  puncture,  introduce  the  silver  direc- 
tor, and  cut  upon  it  with  the  blunt-pointed  bistoury,  in 
order  to  make  an  opening  sufficient  to  admit  the  fin- 
ger. This  is  to  be  considered  the  best  instrument  for 
ascertaining  the  seat  of  the  stricture,  and  the  best  safe- 
guard against  accident.  In  doing  this,  the  blunt-point- 
ed bistoury  should  be  employed,  and  the  sac  freely 
divided  so  as  to  present  a  full  view  of  its  contents. 
The  finger,  with  the  nail  closely  pared,  should  then  be 
carried  up  to  the  neck  of  the  sac,  and  the  seat  of  stric- 
ture is,  in  general,  readily  ascertained. 

At  this  stage  of  the  operation,  it  is  important  to 
recollect  the  relative  position  of  the  epigastric  artery 
and  the  hernial  sac.  In  the  species  of  hernia  of  which 
we  are  now  speaking,  where  the  bowel  passes  down 
through  the  abdominal  canal,  the  artery  is  found  on 
the  inner  side  of  the  neck  of  the  sac ;  while  in  ventro- 
inguinal  hernia  it  lies  upon  the  outside  of  the  neck. 
As  it  is  sometimes  difficult  to  distinguish  these  two 
varieties  of  the  disease,  it  becomes  a  matter  of  import- 
ance to  fix  a  rule  whereby  we  may  escape  the  artery 
in  the  event  of  encountering  either  form. 

Various  directions  have  been  given  by  different  wri- 
ters, in  regard  to  the  direction  of  the  incision  at  the 
ring :  some  have  advised  that  the  surgeon  should  cut 
upward  and  outward ;  while  others,  of  high  character, 
have  recommended  a  directly  opposite  course.  Others 
again,  have  been  determined  in  their  choice  of  direction 
by  the  position  of  the  spermatic  cord. 

These  different  opinions  may  tend  to  confuse  and 
embarrass  the  operator ;  it  is  therefore  the  safest  plan 


<^ 


32  OPERATIONS  FOR    INGUINAL 

for  him  to  follow  the  advice  of  Cooper  and  others  in 
dividing  the  stricture  directly  upvv^ard. 

The  manner  in  which  the  incision  should  be  con- 
ducted, is  an  important  consideration.  The  finger 
should  be  passed  gently  up  to  the  stricture,  and  there 
retained.  The  blunt-pointed  bistoury  should  then  be 
introduced  to  the  same  point,  with  its  side  lying  flat 
upon  the  finger.  Pass  the  instrument  up,  until  it  is  felt 
by  the  finger  to  have  passed  under  the  stricture.  Its 
cutting  edge  should  then  be  carefully  turned  up,  and  a 
very  slight  movement  is  generally  suflicient  to  relieve 
the  strictured  part,  and  enable  the  operator  to  pass  his 
finger  by  the  side  of  the  bowel  into  the  abdomen.  Here 
I  would  remark  that  I  am  not  anxious  to  have  a  sharp 
instrument  for  this  purpose,  for  the  parts  to  be  divided 
are  so  firmly  distended,  that  very  little  cutting  is  re- 
quired to  separate  them ;  and,  by  too  free  an  incision, 
we  may  enlarge  them  unnecessarily,  and  thus  expose 
the  patient  to  the  danger  of  a  return,  or  an  increase  of 
the  protrusion  after  the  operation. 

A  curved  bistoury  with  a  narrow  blade  I  prefer  to 
the  straight  bistoury  of  Cooper,  so  generally  em- 
ployed. The  curved  bistoury  carried  in  tha  pocket- 
case,  the  blade  of  which  is  moveable  on  the  handle,  is , 
often  used.  To  render  the  incision  more  certain  with 
this  instrument,  the  blade  should  be  firmly  secured  to 
the  handle  by  a  tape  string.  I  am  in  the  habit  also  of 
shielding  the  cutting  edge,  to  within  a  short  distance 
of  its  point,  by  wrapping  around  it  a  piece  of  fine  rag 
or  tape. 

The  stricture  may  exist  both  at  the  internal  and 
external  ring,  or  at  either  of  these  points  separately. 
Should  a  stricture  be  discovered  at  the  external  ring, 


AND  FEMORAL  HERNIA.  33 

this  should  be  divided,  and  if  any  difficuhy  occurs,  the 
finger  should  be  passed  on  in  the  direction  of  the  inter- 
nal ring,  to  ascertain  its  state,  before  any  attempts  are 
made  at  reduction.  Should  it  be  impossible  to  reach 
the  strictured  point  by  the  finger,  the  director  must  be 
substituted. 

Having  removed  every  cause  of  obstruction,  we  are 
next  to  return  the  protruded  parts,  supposing  the  case 
to  be  one  in  which  nothing  occurs  to  contra-indicate 
this  course.  This  should  be  done  in  the  gentlest  man- 
ner.  If  the  bowel  does  not  readily  yield,  the  finger 
should  be  again  introduced,  and  a  further  division  of 
the  stricture  made. 

The  reduction  being  effected,  the  surgeon  should 
carefully  examine  the  rings  with  his  finger,  until  he  is 
fully  satisfied  that  all  the  parts  are  in  their  natural 
position.  The  external  wound  should  then  be  lightly 
dressed  with  adhesive  strips;  or,  if  the  incision  has 
been  large,  the  interrupted  suture  may  be  required  as 
an  additional  support.  The  patient  should  be  directed 
to  preserve  as  much  stillness  as  possible,  maintaining 
the  limbs  in  the  flexed  position.  If  restlessness  pre- 
vail, the  system  should  be  kept  under  the  influence  of 
a  moderate  opiate.  The  diet  should  be  scrupulously 
restricted  to  mild,  farinaceous  articles  until  all  risk  of 
inflammation  has  passed  away.  As  a  means  of  main- 
taining the  flexed  position  of  the  limbs,  I  have  found 
great  advantage  in  placing  an  angular  box  and  a  pillow 
under  the  thighs  and  legs  of  the  patient. 

Should  the  bowels  continue  constipated  after  the 

first  effects  of  the  operation  are  over,  small  doses  of 

castor  oil  with  eneinata,  may  be  safely  resorted  to. 

Symptoms  of  inflammation  of  the  peritoneum  may 

5 


34  OPERATIONS  FOR  INGUINAL 

sometimes  follow  the  operation,  owing  to  the  extension 
of  inflammatory  action  from  the  strictured  part : — 
these  should  be  combated  by  the  usual  antiphlogistic 
measures  employed  according  to  the  judgment  of  the 
practitioner. 

As  a  general  rule,  I  would  advise  caution  in  the  em- 
ployment of  rigorous  measures,  to  prevent  apprehended 
danger  after  the  operation.  It  should  ever  be  borne 
in  mind,  that  the  system  has  received  a  severe  shock — 
and  after  the  removal  of  the  cause  which  produced  it, 
some  time  should  be  allowed  for  agitation  to  cease. 
Hence,  mild  and  soothing  treatment,  with  occasional 
opiates,  will  be  more  likely  to  produce  a  happy  result 
than  an  indiscreet  resort  to  rigorous  antiphlogistic 
means.  In  the  subsequent  narration  of  cases,  it  will 
be  seen  that  the  lancet  w  as  very  seldom  employed  after 
the  reduction  of  strangulated  parts. 

I  will  now  offer  a  few  remarks  on  the  operation  for 
femoral  hernia^  which  differs  but  little  from  that  just 
described.  The  tumour  is  generally  much  smaller  in 
this  than  in  inguinal  hernia ;  and  on  this  account  I  pre- 
fer making  a  crucial  incision  through  the  integuments, 
by  pinching  up  the  skin,  as  was  recommended  in  in- 
guinal hernia.  A  free  incision  is  carried  horizontally 
over  the  tumour,  and  another  made  to  cross  it  at  right 
angles.  The  flaps  are  then  carefully  dissected  up,  and 
the  fasciae  divided  with  the  bistoury  and  director  until 
the  sac  is  exposed.  The  sac  in  femoral  hernia  gene- 
rally contains  very  little  fluid,  and  hence  more  caution 
is  required  in  opening  it.  The  situation  of  the  neigh- 
bouring vessels  also  offers  an  additional  reason  for 
deliberate  and  careful  proceeding.  It  will  be  recol- 
lected, that  the  great  femoral  artery  and  vein  are  con- 


AND  FEMORAL  HERNIA.  35 

tained  in  the  same  sheath  which  envelopes  the  hernia, 
and  the  epigastric  artery  should  also  be  borne  in  mind. 
The  last  mentioned  vessel  arises  from  the  external  iliac, 
just  as  it  passes  under  Poupart's  ligament,  where  it 
takes  the  name  of  inguinal  artery;  hence  its  origin  is 
very  near  to  the  outside  of  the  reflected  edge  of  Pou- 
part's ligament,  called  Gimbernat's  ligament,  which  is 
the  seat  of  the  stricture: — a  very  slight  division  of 
the  ligament  outward  would  separate  the  artery  at  its 
origin.  In  dividing  the  stricture,  it  is  important,  if 
possible,  to  have  the  finger  as  a  guide,  and  by  all  means 
to  effect  the  division  upwards,  and  rather  inward. 
Gimbernat  has  advised  to  separate  the  ligament  from 
its  connection  with  the  pubis  : — this  advice  I  consider 
quite  unnecessary,  as  a  very  small  division  is  generally 
effectual. 

Occasionally  the  obturator  artery  diverges  from  its 
usual  course,  and  winds  round  the  neck  of  the  sac. 
Several  specimens  of  this  kind  are  now  in  my  pos- 
session; and  a  case  once  occurred  to  me  in  the  Penn- 
sylvania  Hospital.  I  was  operating  on  a  woman  for 
femoral  hernia,  and  on  introducing  my  finger  to  ascer- 
tain the  seat  of  stricture,  I  could  distinctly  feel  the 
pulsations  of  an  artery  lying  close  to  the  point  of  stric- 
ture. I  was  obliged  to  use  extreme  cautidn  in  pro- 
ceeding, but  by  defending  the  cutting  edge  of  the 
bistoury  till  within  a  short  distance  of  the  point,  and 
by  nibbling,  if  I  may  be  allowed  the  term,  rather  than 
cutting,  I  succeeded  in  dividing  the  stricture  sufficiently 
to  return  the  protruded  parts  without  wounding  the 
artery.  In  this  case,  the  finger  was  an  indispensable 
guide.  The  case  was  interesting  on  some  other  ac- 
counts, and  will  be  narrated  in  the  sequel. 


36  "  PROPRIETY  OF  OPENING 


SECTION  III. 

ON  THE  PROPRIETY  OF  OPENING  THE  HERNIAL  SAC. 

Among  the  important  considerations  associated  with 
the  operations  detailed  in  the  preceding  section,  is  the 
propriety  of  opening  the  hernial  sac,  before  making  any 
attempt  to  return  the  strangulated  parts  into  the  abdo- 
minal cavity.  There  has  long  existed  a  difference  of 
opinion  on  this  subject.  Among  those  distinguished 
surgeons  who  advocate  the  practice  of  opening  the 
sac,  Pott,  Hey,  Astley  Cooper,  and  Samuel  Cooper, 
may  be  named.  Some  more  modern  practitioners 
entitled  to  the  highest  respect  for  their  experience  and 
skill,  have  considered  it  proper  to  dispense  with  this 
part  of  the  operation.  If  the  reduction  of  the  hernia 
can  be  effected  by  a  division  of  the  stricture  without 
opening  the  peritoneum,  they  consider  the  risks  of  the 
operation  ,to  be  greatly  lessened  by  such  a  course. 
Many  older  authorities  are  in  favour  of  this  course  in 
large  and  old  hernia.  Among  the  advocates,  we  may 
mention  Petit,  Monro,  Lawrence,  and,  more  recently, 
Bransby  Cooper. 

For  my  part,  I  am  decidedly  in  favour  of  opening 
the  hernial  sac,  and  I  never  intend  to  perform  the  ope- 
ration without  so  doing.  Differing  in  this  from  some 
of  my  professional  friends  whose  judgment  I  highly 
appreciate,  and  have  often  had  occasion  to  prefer  to 
my  own,  I  feel  bound  to  offer  my  reasons  for  the  prac- 
tice which  is  here  recommended. 

The  principal  objections  to  the  plan  of  opening  the 
sac,  so  far  as  I  can  understand  them,  are  as  follows : — 


THE  HERNIAL  SAC.  37 

In  recent  cases,  the  practice  is  said  to  be  unneces- 
sary, because,  from  the  short  duration  of  the  disease, 
no  serious  mischief  can  have  been  done  to  the  parts, 
and  no  evidence  exists  of  mortification  of  the  bowel ; 
then  why  incur  any  additional  risk  of  peritoneal  in- 
flammation by  making  an  opening  through  this  delicate 
and  susceptible  membrane  ? 

If  efforts  have  been  made  to  reduce  the  contents  of 
the  sac  by  taxis  just  before  proceeding  to  the  opera- 
tion, why  hesitate  to  eflect  the  same  result  after  the 
stricture  is  divided  ?  which  may  be  done  without  open- 
ino-  the  sac. 

While  the  force  of  these  reasons  is  admitted,  they 
have  failed  to  bring  conviction  to  my  mind  of  the  pro- 
priety of  the  course  proposed. 

When  a  patient  labouring  under  strangulated  hernia 
has  submitted  himself  to  a  surgical  operation  for  relief, 
it  becomes  the  duty  of  the  surgeon  carefully  to  weigh 
all  the  circumstances  connected  with  the  case,  to  ba- 
lance in  his  own  mind  the  dangers  to  be  encountered, 
and  in  the  midst  of  contradictory  indications,  to  choose 
the  lesser  evil,  and  draw  forth,  if  possible,  a  safe  and 
happy  result ; — thus  giving  the  confiding  suflTerer  every 
possible  chance  for  life,  by  removing  the  probable 
causes  of  danger. 

Now  it  must  be  familiar  to  every  experienced  sur- 
geon that,  in  cases  of  strangulated  hernia,  there  may  be 
concealed  mischief  within  the  sac,  which  will  certainly 
cause  the  death  of  the  patient  if  not  timely  removed, 
and  which  it  is  impossible  to  ascertain  until  the  sac  is 
laid  open.  It  is  well  understood,  that  the  seat  of  stric- 
ture may  be  in  the  hernial  sac  itself  The  incarcerated 
parts  may  be  returned,  while  the  symptoms  of  stran- 


38  PROPRIETY  OF  OPENING 

gulation  may  go  on  without  the  shghtest  mitigation, 
and  a  fatal  result  will  unfold  the  real  character  of  the 
case. 

The  following  is  an  instance  which  goes  to  show 
the  truth  of  this  remark;  and  as  I  was  concerned  in 
the  case,  with  Dr.  Joseph  P.  Nancrede,  I  have  taken 
the  liberty  of  extracting  it  from  the  sixth  volume  of 
the  Eclectic  Repertory,  where  it  was  first  published. 


CASE  III. 

Seat  of  strangulation  within  the  sac. 

Andrew  Patton,  a  coloured  man  about  thirty  years 
of  age,  strongly  built,  and  of  large  stature,  having 
always  enjoyed  good  health,  had  been  subject  to  a 
scrotal  hernia  on  the  right  side  for  the  last  five  years, 
but  which  being  well  maintained  in  its  situation  by  a 
truss,  had  never  occasioned  the  least  inconvenience. 
On  Friday,  August  10,  while  raising  his  carriage,  (he 
being  a  coachman,)  he  made  an  effort,  which  was  suc- 
ceeded by  a  sudden  pain  in  the  left  groin,  but  which 
appears,  however,  not  to  have  been  sufficiently  acute 
to  excite  alarm,  or  even  to  induce  him  to  examine  the 
spot  which  was  the  seat  of  the  pain.  This  occurred 
about  three  o'clock  in  the  afternoon.  In  the  evening,  as 
usual,  he  returned  home,  complaining  merely  of  fatigue, 
and  went  to  bed  without  any  examination,  although 
the  pain  had  not  abated.  At  about  eleven,  however, 
he  was  roused  by  the  increase  of  his  sufferings,  which 
were  now  so  violent  as  to  make  him  cry  out ;  vomiting 


THE  HERNIAL  SAC.  39 

and  hiccup  made  their  appearance  simultaneously,  and 
the  pain  extending  throughout  the  abdomen,  but  more 
particularly  below  the  navel,  became  excruciating. 
His  sufferings  had  alarmed  him,  and  medical  assistance 
was  requested  at  about  half-past  one. 

Upon  examining  and  questioning  the  patient  as  to 
the  probable  causes  of  his  colic,  (for  thus  it  appeared 
to  me  at  first  sight,)  no  satisfactory  information  could 
be  obtained.  After  some  further  investigation,  how- 
ever, he  recollected  having  felt  in  the  afternoon  a  small 
lump  upon  the  left  groin,  and  added  that  his  most  vio- 
lent pain  had  been  at  this  spot.  This  tumour,  about 
the  size  of  a  goose  egg,  proved  upon  examination  to 
be  a  scrotal  hernia  of  the  left  side,  strangulated. 

Attempts  had  been  already  made  by  the  patient  to 
effect  the  reduction  of  the  tumour,  and  I  repeated 
them  myself  in  vain.  But  finding  the  tumour  very 
hard,  as  well  as  the  pulse,  I  went  home  in  search  of 
my  lancets,  having  previously  administered  a  dose  of 
ol.  ricini.  On  my  return,  however,  after  keeping  the 
muscles  relaxed  for  some  time,  the  hernia  was  almost 
immediately  reduced.  The  patient  soon  felt  relieved, 
the  pain  disappeared,  not  the  least  vestige  of  the  tu- 
mour remained,  and  I  left  him  dosing. 

A  couple  of  hours  afterwards,  the  symptoms  of 
strangulation  were  renewed,  and  continued  the  same 
as  previous  to  the  reduction  of  the  hernia.  No  evacua- 
tion having  taken  place,  a  second  dose  of  ol.  ricini  was 
ordered,  but  was  almost  immediately  vomited.  A  third 
cathartic,  which  he  kept  down,  produced  no  effect 
whatever.  It  was  then  deemed  necessary  to  take  ten 
ounces  of  blood  from  the  arm,  which,  however,  failed 
to  procure  any  relief.     At  twelve  in  the  forenoon,  no 


40  PROPRIETY  OF  OPENING 

abatement  of  the  pain  could  be  perceived,  although 
the  pulse  was  softer;  but  the  vomiting  and  hiccups 
had  disappeared.  No  passage  had  yet  been  procured ; 
a  dose  of  calomel  and  jalap  was  therefore  prescribed. 
Having  seen  him  a  third  time  in  the  afternoon,  and  no 
amelioration  being  visible,  the  abdomen  becoming  pain- 
ful to  the  touch,  and  tumefied,  and  still  no  evacuation, 
a  second  dose  of  calomel  with  emollient  injections 
were  recommended,  and  the  patient  w^as  bled  a  second 
time.  The  same  situation  manifested  itself  in  the 
evening,  when  the  patient  was  again  bled  for  the  third 
time.  Although  the  reduction  of  the  pulse  was  con- 
siderable, yet  it  procured  no  relief.  The  vomitings 
had  occurred  twice  in  the  afternoon.  Fomentations 
on  the  abdomen  were  ordered  with  the  injections,  but 
with  the  exception  of  a  little  relaxation  in  the  tension 
of  the  abdomen,  no  effect  was  produced.  An  infusion 
of  senna  was  administered,  also  in  vain.  I  visited  him 
early  on  the  morning  of  Sunday  the  12th,  and  found 
that  his  sufferings  had  not  increased,  although  he  had 
experienced  no  rehef.  He  had  not  slept  any  during 
the  night.  The  abdomen  continued  painful  and  tume- 
fied, but  he  complained  much  more  of  pain  in  the  groin 
on  the  right  side  than  at  any  other  point.  No  passage. 
The  injections,  fomentations,  and  the  infusion  of  senna 
were  directed  to  be  continued.  The  pulse  had  become 
tense  and  tremulous. 

The  case  proving  obstinate,  I  requested  the  advice 
of  my  friend  and  neighbour.  Dr.  Povall,  who  agreed  in 
opinion  that  the  symptoms  of  strangulation  most  pro- 
bably arose  from  a  stricture  in  the  hernial  sac,  that 
had  been  reduced  with  the  intestine.  It  was  deter- 
mined, at  his  suggestion,  to  apply  a  large  blister  on 


THE  HERNIAL  SAC.  41 

the  abdomen,  and  to  insist  upon  the  injection  of  large 
quantities  of  warm  water,  with  the  hope  of  overcom- 
ing the  obstruction  which  existed.  The  bhster  did  not 
produce  on  the  skin  or  system  any  effect  whatever, 
and  the  other  remedies  made  use  of  were  equally  in- 
effectual. A  copious  bleeding  was  ordered  in  the  after- 
noon, owing  to  the  hardness  of  the  pulse.  The  night 
from  Sunday  to  Monday  was  equally  restless.  On 
Monday,  his  situation  continuing  the  same,  it  was 
agreed  between  Dr.  P.  and  myself  that  a  dose  of  gum 
gamb.  and  calomel  should  be  given,  and  cold  water 
poured  on  the  lower  extremities.  No  effect  whatever 
from  either.  His  sufferings  were  as  great  as  the  day 
previous.  The  vomiting  and  some  hiccup  had  occur- 
red, but  gave  way  to  the  camphorated  mixture,  which 
was  now  recommended. 

On  Tuesday  morning  his  pulse  wias  considerably  de- 
pressed, the  tension  of  the  abdomen  had  subsided,  and 
it  was  much  less  painful ;  but  the  extremities  were  cold, 
accompanied  by  clammy  sweats.  The  voice  had  un- 
dergone some  alteration ;  constant  anxiety  and  restless- 
ness were  also  observed.  The  injections  were  conti- 
nued during  the  day,  and  a  decoction  of  tobacco  was 
also  added.  Notwithstanding  the  treatment,  the  in- 
flammation maintained  its  ground.  No  passage  could 
be  procured.  Several  medical  gentlemen  saw  the  pa- 
tient in  the  course  of  this  day,  and  agreed  with  me  in 
the  opinion  that  very  little  hope  could  be  entertained. 
At  the  suggestion  of  one  of  the  gentlemen,  quicksilver 
was  administered,  in  the  proportion  of  an  ounce,  but 
also  in  vain.  Dr.  Parrish  was  called  to  see  the  pa- 
tient in  consultation  on  Wednesday,  and  concurred  in 

6 


42  PROPRIETY  OF  OPENING 

opinion  with  Dr.  Povall  and  myself  as  to  the  probable 
cause  of  the  very  dangerous  symptoms. 

The  pulse  continued  to  sink,  and,  with  some  remis- 
sion, when  it  would  rise  in  an  unaccountable  manner, 
gradually  lost  both  its  strength  and  regularity.  Vomit- 
ing, but  more  especially  the  hiccup,  became  very  trou- 
blesome ;  and  the  least  motion  produced  fresh  pains. 
The  camphorated  solution  was  of  service  in  reheving 
the  patient  from  the  hiccup.  In  this  situation,  when 
every  remedy  had  failed,  he  kept  lingering  until  the 
night  of  Thursday  to  Friday,  when  he  expired — the 
seventh  day  of  his  disease. 

I  proceeded  the  next  morning  to  the  opening  of  the 
body,  accompanied  by  Dr.  Povall. 

On  opening  the  abdomen,  we  found  the  whole  mass 
of  the  intestinal  tube,  commencing  at  the  strictured 
part  and  extending  upwards,  distended  with  air :  the 
vessels  of  the  omentum,  as  well  as  those  of  the  mesen- 
tery, very  much  injected  with  blood,  and  the  greater 
portion  of  the  intestines  bearing  evident  marks  of  in- 
flammation. The  seat  of  the  disease,  however,  was 
confined  to  the  jejunum,  which,  for  the  length  of  twelve 
inches,  had  lost  its  colour,  and  was  in  a  complete  state 
of  sphacelus.  A  portion  of  this  intestine  was  confined 
in  the  inner  portion  of  the  abdominal  ring,  where  the 
hernial  sac  formed  a  stricture  round  it,  which  having 
also  participated  in  the  general  mortification,  w^as  to- 
tally disorganized,  and  could  easily  be  torn  away  by 
the  nail.  So  complete  had  been  this  adhesion,  that 
when  it  was  ruptured  by  a  very  slight  eflbrt,  a  hole  in 
the  intestinal  canal,  about  the  size  of  a  shilling,  was 
produced.     We  also  noticed  another  hole  near  it,  of 


THE  HERNIAL  SAC.  43 

the  same  size,  having  all  the  appearance  of  an  ulcer. 
Having  cut  open  the  intestine  at  its  most  diseased 
point  for  a  few  inches,  pus,  and  a  remarkable  black 
appearance  on  the  internal  coat,  were  observed.  A 
remarkable  spot  about  the  size  of  a  half  dollar  attract- 
ed our  attention.  It  was  situated  about  the  middle  of 
the  transverse  portion  of  the  colon.  It  was  very  evi- 
dent to  us,  that  the  intestines  contained  in  the  right 
side  of  the  abdomen,  but  more  particularly  in  its  lower 
region,  had  been  the  seat  of  a  more  extensive  and  acute 
inflanuuation  than  those  situated  on  the  left.  The  in- 
guinal ring,  which  was  diseased,  as  we  have  already 
noticed,  on  the  left  side,  had  protruded  in  the  abdomen 
as  much  as  an  inch,  by  the  increase  of  its  volume. — 
Eclectic  Repertory^  vi.  p.  531. 

But  there  is  still  another  cause  of  strangulation  which 
may  continue  even  after  the  protruded  parts  are  re- 
turned into  the  abdomen,  and  which  the  surgeon  can- 
not discover  if  the  sac  has  not  been  laid  open.  The 
omentum  itself  may  become  entwined  around  a  portion 
of  the  bowel,  causing  fatal  strangulation.  There  are 
several  cases  of  this  kind  to  be  found  in  the  books,  and 
Ledran  mentions  an  instance  in  which  a  portion  of  the 
omentum  adhered  to  the  surface  of  the  sac  of  a  crural 
hernia,  so  that  it  formed  a  kind  of  bag  within  a  bag, 
and  produced  such  a  narrowing  of  the  neck  that  the 
intestine  could  not  be  returned  without  opening  the 
sac,  and  dividing  the  omentum.* 

These  instances  present  unquestionable  evidence  of 
danger  and  death,  which  probably  might  be  prevented, 

*  See  Ledran — Observations  in  Surgery.     Translated  by  J.  S.,  Sur- 
geon, p.  190.     London,  1758. 


44  PROPRIETY  OF  OPENING 

if  the  sac  were  opened,  and  the  actual  seat  of  stricture 
made  known  to  the  operator. 

Again :  the  return  of  the  mortified  portion  of  bowel 
or  omentum  within  the  abdomen,  must  be  accompanied 
with  great  danger;  for  the  moment  a  part  is  positively 
dead,  from  that  moment  it  becomes  extraneous  matter, 
and  cannot  fail  to  be  a  source  of  irritation  and  conse- 
quent danger  to  the  patient.  I  am  aware  of  the  diffi- 
culty of  reducing  mortified  bowel  or  omentum,  in  con- 
sequence of  the  adhesion  produced  by  the  preceding 
inflammation ;  but  if  the  stricture  be  divided,  I  believe 
it  may  sometimes  be  done. 

The  symptoms  which  denote  the  existence  of  mor- 
tified bowel  or  omentum  are  extremely  deceptive,  as 
will  be  shown  in  the  proper  place ;  and  the  time  re- 
quired to  effect  the  death  of  strangulated  parts  is  very 
various.  The  force  of  the  stricture,  and  the  pecu- 
harity  of  the  constitution  may,  in  some  instances,  pro- 
duce very  rapid  disorganization. 

Hence,  it  may  happen,  after  a  division  of  the  stric- 
ture, without  opening  the  sac,  that  a  mortified  portion 
of  its  contents  may  be  pushed  into  the  cavity  of  the 
belly,  perhaps  without  the  operator  having  the  slightest 
apprehension  of  the  real  state  of  the  case,  which  could 
only  be  revealed  by  an  exposure  of  the  parts. 

Let  us  now  examine  the  most  formidable  objection 
to  the  practice  of  opening  the  sac.  It  is  the  danger 
of  peritoneal  inflammation,  in  consequence  of  forming 
a  communication  with  the  external  air. 

That  peritoneal  inflammation  is  a  very  dangerous 
and  fatal  disease,  is  a  fact  well  known  to  every  exten- 
sive  practitioner.  The  physician  may  meet  with  it 
occasionally  in  its  most  aggravated  form,  without  any 


THE  HERNIAL  SAC.  45 

connexion  with  a  wound  or  an  external  injury.  I 
consider  idiopathic  peritonitis  as  a  rare  disease,  when 
unconnected  with  puerperal  fever.  I  have  met  with 
it  in  a  few  instances  in  young  persons,  where,  for 
several  days,  its  approach  has  been  most  insidious, 
being  marked  by  a  bending  of  the  body  forward,  and 
where  dissection  has.  revealed  evidence  of  violent  in- 
flammation with  sero-purulent  effusion.  Its  occur- 
rence in  puerperal  fever  is  familiar  to  all.  Here  we 
find  the  disease  dependent  on  some  obscure  constitu- 
tional cause,  predisposing  the  system  to  violent  inflam- 
matory action  in  a  particular  part. 

"  Causa  latet — vis  est  notissiraa." 

I  exclude  from  this  view  the  various  modifications 
of  diseased  action  which  may  arise  in  the  progress  of 
fevers,  &c.  and  which  constitute  the  mere  sequel  of 
acute  forms  of  disease. 

Let  us  now  take  up  the  subject  in  a  surgical  point 
of  view,  and  inquire  whether  peritoneal  inflammation 
is  as  frequent  as  might  be  theoretically  supposed,  even 
in  cases  in  which  the  peritoneum  is  opened  by  accident 
or  intention. 

May  T  not  hazard  the  opinion,  that  when  there  exists 
none  of  those  unseen  and  unknown  causes  of  consti- 
tutional predisposition  to  peritoneal  inflammation  to 
which  1  have  referred,  this  membrane  may  be  opened 
with  less  risk  to  the  life  of  the  patient  than  is  gene- 
rally supposed.  Take,  for  example,  the  operation  of 
tapping  in  ascites.  This  is  of  very  frequent  occur- 
rence, and  here  the  peritoneum  is  punctured.  I  have 
seen  leakage  through  the  wound  take  place  for  seve- 


46  PROPRIETY  OF  OPENING 

ral  days  without  injury  to  the  patient,  and  I  would 
appeal  to  the  experience  of  the  medical  profession,  as 
to  the  frequency  of  inflammation  and  death,  as  a  direct 
consequence  of  paracentisis  abdominis.  I  may  have 
seen  inflammation,  as  a  very  rare  occurrence,  after 
this  operation,  but  I  believe  I  may  safely  assert,  that 
I  have  never  known  a  case  resulting  in  death,  from 
tapping  the  abdomen  in  dropsy. 

I  have  known  an  instance  of  a  small  shot  entering 
the  abdomen  and  penetrating  an  intestine,  to  be  fol- 
lowed, soon  after,  by  a  copious  stool  of  fresh  blood 
from  the  bowels,  and  yet  the  patient  recovered,  with- 
out any  serious  symptoms. 

Those  surgeons  who  are  acquainted  with  surgical 
practice  as  it  existed  many  years  ago,  must  be  fami- 
liar with  the  views  then  entertained  of  the  dangers 
resulting  from  openings  into  the  cavities  of  the  joints 
in  luxations  and  fractures,  and  which  were  founded  on 
the  same  reasoning  which  now  occasions  the  dread  of 
peritoneal  inflammation,  when  a  cavity  is  exposed. 
The  numerous  recoveries  from  injuries  of  this  class, 
under  the  present  improved  mode  of  practice,  induce 
us  to  believe  that  the  anticipation  of  dreadful  results 
often  led  to  unnecessary  mutilation. 

From  the  views  now  unfolded,  I  should  hope  that 
no  young  and  inexperienced  practitioner  would  pre- 
sume recklessly  to  institute  operations  involving  the 
peritoneum,  and  plead  me  as  his  authority.  My  object 
is  simply  to  show,  that  in  endeavouring  to  balance 
the  dangers  of  omitting  to  open  the  hernial  sac,  and 
the  dangers  consequent  upon  the  opening,  I  have  long 
since  arrived  at  the  settled  conclusion,  that  to  open 
the  hernial  sac,  and  thus  make  a  full  exposure  of  its 


THE  HERNIAL  SAC.  47 

contents,  is  the  lesser  evil,  and  the  practice  most  likely 
to  conduce  to  the  welfare  of  the  patient.  Even  if  in- 
flammation should  follow  after  such  an  operation,  may 
not  the  injury  inflicted  on  the  bowel  by  severe  stran- 
gulation be  taken  into  the  account,  as  at  least  one  of 
the  prominent  causes,  inasmuch  as  we  knoAv  that  parts 
are  frequently  returned  into  the  abdomen,  in  a  state  of 
high  inflammation  ? 


SECTION  IV. 

DIFFICULTIES  OF  OPENING  THE  HERNIAL  SAC. 

It  might  be  supposed,  a  priori,  that  the  hernial  sac 
could  be  opened  without  the  slightest  difficulty,  after 
having  been  fairly  brought  into  view  by  careful  dissec- 
tion. That  this  is  the  fact,  is  fully  admitted  in  all 
those  cases  where  the  hernia  is  large,  and  where  the 
sac,  as  is  usual,  contains  a  considerable  quantity  of 
serous  fluid. 

It  is  said  that,  by  careful  examination,  you  may  feel, 
through  the  sac,  the  cleft  between  the  sides  of  the  pro- 
truded bowel.  I  can  admit  the  possibility  of  such  a 
case,  provided  it  was  left  to  the  choice  of  the  surgeon 
to  direct  the  manner  in  which  the  descent  of  strangu- 
lated parts  shall  take  place;  but  if  a  portion  of  omen- 
tum, for  example,  should  be  involved  in  the  mischief, 
and  should  be  found  in  the  anterior  part  of  the  sac, 
covering  the  intestine,  would  it  not  prove  somewhat  of 
a  barrier  while  searching  for  this  cleft?  The  efflision 
of  lymph  which  we  often  find  as  the  result  of  inflam- 
mation nmst  cause  very  considerable  derangement  in 


48  DIFFICULTIES  OF  OPENING 

the  natural  situations  of  the  parts,  and  thus  increase 
the  obscurity.  If  these  remarks  apply  to  a  hernia  of 
large  size,  with  what  increased  force  do  they  bear  upon 
a  very  small  portion,  or  knuckle  of  bowel,  especially 
in  femoral  hernia !  Here,  it  is  utterly  impossible  to  dis- 
tinguish any  cleft  between  the  sides  of  the  intestine. 

It  is  said  tliat  the  blood-vessels  of  the  intestine,  and 
its  smooth,  polished  surface  distinguish  it  from  the 
hernial  sac,  which  has  not  those  blood-vessels,  which 
is  rather  rough  and  cellular  on  its  surface,  and  which 
is  always  connected  with  the  surrounding  parts.  After 
some  experience  in  this  matter,  I  acknowledge  myself 
unable  to  draw  these  nice  distinctions  in  living  struc- 
tures, sometimes  not  inconsiderably  altered  by  diseased 
action.  Having  often  found  difficulty  in  distinguish; 
ing  between  sac  and  intestine,  and  felt  the  vast  import- 
ance of  avoiding  the  danger  of  inflicting  a  wound  on 
the  latter  while  opening  the  former,  I  am  willing  to 
communicate  my  experience  on  the  subject.  Let  it 
be  remembered  that,  especially  in  some  cases  where  a 
small  portion  only  of  bowel  is  incarcerated,  there  is 
no  fluid  in  the  hernial  sac,  and  the  parts  are  so  identi- 
fied, that  to  make  a  proper  discrimination  is  a  very 
difficult  task. 


CASE  IV. 


Hernial  Sac  concealed  by  a  coaguhim  of  blood. 

3d  mo.  10th,  1830. — W.  H.,  a  native  of  the  West 
Indies,  aged  about  38  years,  was  admitted  into  the 
Pennsylvania  Hospital  about  8  o'clock,  P.  jyi. 


THE  HERNIAL  SAC.  49 

The  following  is  the  history  of  the  case. 

The  patient  had  been  affected  with  a  femoral  hernia 
for  some  years,  and  for  the  last  two  years  had  worn 
a  truss.  A  few  days  previous  to  his  attack,  his  truss 
was  stolen  from  him,  since  which  time  he  had  suffered 
more  or  less  pain  in  his  rupture.  About  7  o'clock, 
on  the  morning  of  his  admission,  he  was  seized  with 
pain  and  vomiting,  and  was  unable  to  return  the  bowel. 
In  the  afternoon,  he  was  visited  by  my  friend.  Dr. 
Atlee,  who  directed  for  him  free  venesection  and  a 
tobacco  enema.  After  this,  I  visited  him  with  Dr. 
Atlee,  and  advised  his  being  sent  to  the  Hospital,  to 
which  the  patient  consented.  For  several  hours  pre- 
vious to  his  arrival  at  the  Hospital  he  had  been  affect- 
ed with  singultus. 

9  P.  M.  I  met  my  colleagues,  Drs.  Hewson  and 
Hartshorne,  and  on  examining  the  case,  the  operation 
was  concluded  on  at  once.  Sixty  drops  of  laudanum 
were  directed,  after  which,  about  twenty  minutes  were 
spent  in  preparing  for  the  operation. 

The  tumour  was  unusually  large  for  a  femoral  her- 
nia, and  of  an  oval  figure,  its  longest  diameter  being 
across  the  groin. 

I  made  a  crucial  incision  over  the  tumour,  pursuing 
the  dissection  in  the  usual  manner,  until  I  arrived  at 
a  membrane,  which  I  supposed  to  be  the  sac :  I  thought 
it  was  remarkably  thick.  After  repeated  trials,  I  failed 
to  pinch  up  the  membrane  in  the  usual  way,  owing  to 
its  firmness  and  thickness.  I  therefore  cut  it  very 
cautiously  with  the  scalpel,  being  careful  not  to  pene- 
trate it. 

After  paring  off  a  small  portion  in  this  manner,  I 

was  enabled  to  take  hold  of  a  surrounding  portion 


50  DIFFICULTIES  OF  OPENING 

with  a  forceps,  and  to  continue  cutting  obliquely  up- 
ward until  I  had  removed  a  considerable  portion  of 
the  membrane.  Underneath  this  we  discovered  a  layer 
of  coagulated  blood,  of  a  very  dark  colour. 

The  question  now  arose,  whether  I  had  penetrated 
the  sac,  and  whether  the  coagulum  just  noticed  was 
thrown  out  around  the  bowel  and  had  been  adherent 
to  the  internal  surface  of  the  sac.  This  might  have 
occurred,  provided  the  sac  contained  no  fluid,  which 
sometimes  happens.  While  this  question  was  under 
discussion,  I  pressed  my  finger  firmly  upon  the  coagu- 
lum, and  thought  I  could  distinctly  discover  fluctua- 
tion below.  On  examination,  my  colleagues  were  of 
the  same  opinion,  and  we  decided  that  the  sac  was 
still  undivided. 

On  scraping  away  the  coagulum,  the  sac  was  dis- 
tinctly seen  below.  Dr.  Hartshorne  succeeded  in  get- 
ting a  portion  of  it  between  his  fingers,  and  I  cut  through 
it  in  the  usual  manner.  On  opening  the  sac,  a  small 
quantity  of  dark,  bloody  fluid  escaped.  I  now  dilated 
the  opening  freely,  with  the  blunt-pointed  bistoury, 
and  passing  up  my  finger,  exposed  a  portion  of  the  in- 
carcerated bowel.  The  bowel  was  but  little  altered 
from  its  natural  appearance.  The  seat  of  stricture 
was  at  Gimbernat's  ligament;  this  was  distinctly  felt 
with  the  index  finger  of  the  left  hand;  the  blunt-pointed 
bistoury  was  passed  up,  the  stricture  was  divided,  and 
the  intestine  was  reduced  without  difficulty.  The 
wound  was  closed  by  the  interrupted  suture,  and  the 
patient  placed  in  bed,  with  directions  to  have  adminis- 
tered a  dose  of  laudanum  if  he  became  restless,  and  if 
fever  ensued,  blood  to  be  abstracted.  Barley-water 
ordered  for  drink  and  nutriment. 


THE  HERNIAL  SAC,  51 

llth,  morning. — Patient  had  passed  a  good  night. 
Pulse  68  strokes  in  the  minute.  Symptoms  of  stran- 
gulation ceased  immediately  after  the  operation.  Di- 
rected ol.  ricini  5ss.  every  three  hours,  until  the  bowels 
are  moved.  Continue  barley-water.  Evening.  Bowels 
not  moved.  Pulse  85.  Directed  oleaginous  mixture 
every  two  hours,  until  it  operates. 

\2th. — Pulse  80.  Patient  rested  w^ell  during  the 
night,-  had  two  copious  evacuations.  Continue  the 
barley-w^ater,  and  the  oleaginous  mixture. 

13M. — Pulse  80.  Patient  has  taken  gi.  of  oil  since 
yesterday ;  has  had  but  one  discharge  from  the  bowels. 
Directed  a  diet  of  oat-meal  gruel,  well  sweetened. 
The  wound  has  united  sufficiently  to  allow  the  ligatures 
to  be  cut  out.     Continue  the  oleaginous  mixture. 

\Ath. — Pulse  72.  The  bowels  have  been  opened 
once  since  the  last  visit.  Ordered  to  continue  the 
oleaginous  mixture. 

15/A. — Three  stools  have  passed  since  the  last  re- 
port.    The  wound  looks  well.     Pulse  68. 

19//i. — The  wound  is  now  cicatrizing.  The  pulse 
and  tongue  present  a  natural  appearance,  and  the 
bowels  are  sufficiently  opened. 

22d. — The  patient  placed  on  an  improved  diet.  Or- 
dered chicken  broth,  toast,  butter,  &c. 

Ath  mo.  6th. — Discharged,  cured. 


52  DIFFICULTIES  OF  OPENING 


CASE  V. 

Distinction  between  Sac  and  Intestine  confused  by  Gan- 
grene. 

9th  mo.  29,  1822. — I  attended  this  evening,  with  my 
colleagues,  at  the  Pennsylvania  Hospital,  in  an  in- 
teresting case  of  strangulated  femoral  hernia,  in  which 
Dr.  Price  performed  the  operation.  .  The  tumour  was 
unusually  small.  In  dissecting  down  through  the  in- 
teguments and  fascia?,  the  operator  readily  reached 
what  we  all  supposed  to  be  the  hernial  sac.  The  parts 
were  in  an  evident  state  of  sphaoelation,  and  the  most 
prominent  part  of  the  intestine,  as  far  as  we  could 
judge  by  candle-light,  was  of  an  ash-gray  colour. 

There  w^as  great  difficulty  in  distinguishing  between 
sac  and  intestine.  At  Dr.  Hartshorne's  suggestion, 
the  parts  were  pinched  up  between  the  fingers,  and  we 
perceived — very  evidently,  as  we  thought — the  sac,  dis- 
tinct from  the  intestine.  We  could  feel  fluctuation  in 
the  part,  as  if  it  contained  a  fluid.  By  our  advice,  Dr. 
Price  cut  through  the  parts  contained  between  his  fin- 
gers, and  opened  at  once  into — the  intestine — the  con- 
tents of  which  escaped. 

On  a  more  minute  examination,  we  discovered  that 
the  part  divided  was  the  anterior  portion  of  the  intes 
tine,  which  was  in  a  state  of  mortification,  and  was 
very  flaccid.  The  deception  was  occasioned  by  the 
flaccid  state  of  the  dead  bowel,  contrasted  with  the 
firm  and  thickened  living  portion  around  it,  giving  the 
idea  of  a  thin  membrane,  covering  a  firmer  one.     It  is 


THE  HERNIAL  SAC.  53 

true  that  no  harm  was  done  by  the  opening  in  this  case, 
but  it  exhibits  a  striking  example  of  the  difficuhy  of 
distinguishing  between  the  sac  and  intestine,  under  par- 
ticular circumstances. 

The  case  was,  in  every  respect,  unpromising ;  the 
expression  of  the  countenance  w^as  unpleasant,  but  nei- 
ther the  pulse,  skin,  or  tongue  gave  evidence  of  mor- 
tification. 


CASE  VI. 

Hernial  Sac  at  first  mistaken  for  Intestine, 

Wth  mo.  25tk,  1818. — I  was  called,  this  morning,  by 
my  friend.  Dr.  George  B.  Wood,  to  visit  with  him  a 
female  domestic,  who  lived  in  the  family  of  a  respect- 
able apothecary,  and  who  was  labouring  under  stran- 
gulated femoral  hernia. 

She  was  attacked  with  symptoms  of  strangulation, 
on  the  21st  inst.  and  was  supposed,  by  her  friends,  to 
be  labouring  under  bilious  colic.  The  apothecary  had 
prescribed  several  articles  for  her  relief,  all  of  which 
were  rejected  by  the  stomach.  Soon  after  the  attack, 
she  had  one  discharge  from  the  bowels ;  after  which 
they  were  confined,  notwithstanding  the  frequent  use 
of  injections.  A  blister  had  also  been  applied  to  the 
abdomen. 

On  the  25th,  Dr.  Wood  was  called  to  see  her,  and, 
from  her  symptoms,  at  once  suspected  strangulated 
hernia.  She  was  cold  and  nearly  pulseless.  The  doc- 
tor requested  that  her  female  attendants  should  exa- 
mine her  groins ;  from  motives  of  false  delicacy,  the 


54  DIFFICULTIES  OF  OPENING 

patient  resisted,  and  several  hours  elapsed  before  the 
necessary  examination  was  made ;  it  was  then  ascer- 
tained that  she  had  a  small  tumour  in  the  groin,  and, 
at  the  request  of  Dr.  Wood,  I  attended  in  consulta- 
tion. 

I  found  the  patient  with  a  cold  skin ;  a  very  feeble 
pulse ;  the  tongue  moist  and  slightly  furred ;  the  abdo- 
men tumid,  and  tender  to  the  touch ;  the  countenance 
sunken;  and  the  patient  complaining  very  much  of 
general  distress  and  wretchedness.  The  tumour  was 
situated  in  the  right  groin ;  it  was  small,  and  of  an 
oval  figure. 

The  symptoms  were  so  extremely  unfavourable, 
that  I  was  doubtful  of  the  propriety  of  an  operation, 
but  in  order  to  give  the  poor  woman  every  chance, 
Drs.  Hewson  and  Hartshorne  were  called  in  consulta- 
tion, at  my  request.  They  advised  against  the  opera- 
tion ;  the  patient  appearing  to  be  in  articulo  mortis. 
We  left  her  for  the  night,  advising  anodynes  to  be 
given  to  lessen  her  distress.  One  of  my  pupils  remain- 
ed with  her. 

26th. — We  met  in  consultation  in  the  morning,  and, 
to  our  great  surprise,  the  system  had  reacted  consider- 
ably. Her  skin  was  warm,  And  her  pulse,  though  very 
feeble,  had  evidently  improved.  The  pupil  reported 
that  she  had  been  delirious  in  the  night,  rose  from  her 
bed,  and  insisted  upon  walking  to  the  fire  for  some 
minutes,  and  then  walked  back  to  her  bed  without  dif- 
ficulty. The  favourable  change  in  the  patient's  symp- 
toms induced  us  to  recommend  the  operation,  which  I 
performed,  assisted  by  Drs.  Hewson,  Hartshorne,  Har- 
lan, and  Wood,  in  the  presence  of  several  of  my  pupils. 

A  crucial  incision  was  made  over  the  tumour,  and 


THE  HERNIAL  SAC.  55 

the  fasciae  divided  by  the  director  and  bistoury,  in  the 
usual  manner,  until  I  thought  I  had  opened  the  sac 
and  exposed  a  portion  of  intestine,  that  appeared  to  be 
adhering  to  it.  I  passed  my  finger  down  by  the  side 
of  the  supposed  bowel,  but  could  not  feel  the  ligamen- 
tory  edge  which  was  the  seat  of  stricture.  My  friends, 
Hewson  and  Hartshorne  also  examined,  and  were 
equally  unsuccessful. 

Dr.  Hewson  now  suggested  that  the  sac  was  still 

DO 

unopened,  and  on  close  investigation  this  was  found  to 
be  the  case.  The  part  which  we  had  supposed  to  be 
intestine  was  the  sac,  and,  by  careful  examination,  the 
strangulated  contents  could  be  felt  within  it.  I  suc- 
ceeded in  making  an  opening  very  cautiously  in  the 
sac.  No  fluid  was  contained  in  it,  which  circumstance 
rendered  the  obscurity  so  great.  A  portion  of  omen- 
tum w^as  found  in  a  state  of  mortification,  and  a  small 
fold  of  bowel  on  the  side  next  the  omentum  had  an  ash- 
coloured  slough.  The  cadaverous  smell  was  observable 
immediately  on  opening  the  sac.  The  stricture  was 
divided  without  difficulty,  and  the  patient  bore  the 
operation  very  well. 

She  was  put  to  bed ;  a  soft  poultice  was  applied  to 
the  wound,  (a  piece  of  gauze  intervening,)  and  wine 
was  directed  in  small  quantities.  I  called  in  about  an 
hour  after  the  operation,  and  found  her  complaining  of 
most  severe  pain  in  the  lumbar  region.  Her  abdomen, 
which  was  tympanitic  before  the  operation,  appeared 
to  have  increased  in  size.  I  was  about  to  introduce  a 
tube  into  the  colon,  for  the  purpose  of  extracting  the 
air  by  the  syringe,  when  she  was  seized  with  vomiting, 
and  the  contents  of  her  stomach  were  discharged  over 
the  bed-clothes  and  floor.     After  this,  she  called  to 


56  DIFFICULTIES  OP  RETURNING 

her  daughter,  and,  in  an  audible  voice,  directed  her  to 
go  down  stairs  and  bring  up  a  cloth  to  wipe  the  floor; 
and  in  less  than  five  minutes  after  giving  the  direc- 
tion— she  expired. 


CASE  VII. 

Inguinal  Hernia — Stricture    iti  the  Sac — Adhesion   of 

Omentum. 

5th  mo.  13th  1816. — I  was  called  this  day  in  con- 
sultation with  Drs.  Betton  and  Moore,  to  visit  a  labour- 
ing man,  at  Peter  Robinson's  mill,  Roxborough.  The 
patient  had  a  small  strangulated  rupture  on  the  left 
side.  It  could  scarcely  be  called  scrotal,  but  was  rather 
a  bubonocele.  He  had  been  bled  very  freely,  and  vari- 
ous unsuccessful  eflforts  had  been  made  to  relieve  him 
by  Drs.  Betton  and  Moore.  The  strangulation  had 
existed  between  seventy  and  eighty  hours. 

As  we  were  all  united  in  opinion  that  no  time  was 
to  be  lost,  and  as  the  patient  consented  to  the  opera- 
tion, a  dose  of  laudanum  was  exhibited,  and,  wdth  the 
assistance  of  my  medical  friends,  I  proceeded  to  per- 
form it. 

After  making  the  usual  incision  through  the  integu- 
ments, and  taking  up  several  small  arteries,  I  came 
down  to  the  hernial  sac.  It  was  found  to  be  thickened, 
and  contained  no  fluid.  Here  a  difficulty  arose ;  and 
much  care  was  required  to  avoid  wounding  the  parts 
within  the  sac.  It  was  soon  ascertained,  that  the  pa- 
tient had  an  irreducible  omental  hernia,  closely  adher- 


FROM  INFLAMMATION.  57 

ing  to  the  sac.  It  required  no  little  time  and  great 
care  to  separate  the  adhesion  and  expose  the  omen- 
tum. After  this  was  accomplished,  no  intestine  was 
apparent,  although  the  symptoms  of  strangulated 
bowel  were  clearly  marked.  It  was  soon  discovered 
that  there  was  a  small  but  very  tight  stricture  in  the 
hernial  sac  itself,  not  far  from  the  abdominal  ring. 
This  was  divided  by  the  aid  of  a  small  director  and 
bistoury.  It  was  not  until  this  was  accomplished, 
and  the  parts  were  unbound,  that  the  real  character  of 
the  case  was  made  to  appear.  The  liberated  omen- 
tum was  laid  on  one  side,  and  a  small  portion  of  stran- 
gulated intestine  was  exposed.  But  the  difficulty  had 
not  terminated  even  now,  for  the  intestine  was  still 
bound  by  a  stricture  at  the  abdominal  ring,  which  I  di- 
vided with  the  blunt-pointed  bistoury  and  director.  The 
intestine  was  inflamed,  but  not  gangrenous.  The  omen- 
tum was  of  a  dark  colour.  I  now  reduced  the  intes- 
tine without  difficulty,  and  it  was  concluded  that  the 
omentum  should  remain  undisturbed.  The  wound  was 
dressed,  and  the  patient  put  to  bed.  I  left  him  under 
the  care  of  his  medical  attendants.  He  recovered 
most  happily,  and  called  on  me,  not  long  afterwards, 
in  the  city. 


It  occasionally  happens  that  the  inflammation  which 
occurs  in  the  strangulated  parts,  produces  adhesions 
between  the  contents  of  the  hernial  sac,  more  particu- 
larly in  the  vicinity  of  the  stricture,  and  between  the 
folds  of  the  intestine,  which  may  prove  a  source  of 
difficulty  in  the  operation.  The  following  case  is  an 
instance  of  this  kind. 

8 


58  DIFFICULTY  OF  REDUCTION 


CASE  VII. 

Strangulated  Ventro-inguinal  Hernia — Adherent  Intes- 
tine— Cure. 

8th  mo.  10th,  1834.  I  was  called  this  afternoon  by 
Dr.  George  Uhler,  to  see  M.  G.  a  patient  about  seventy- 
two  years  old,  who  has  been  under  the  care  of  Dr. 
Uhler  for  about  one  year,  with  hydrothorax,  and  occa- 
sionally slight  ascites,  wdth  anasarca  of  the  legs. 

M.  has  been  subject  to  hernia  for  twenty  years,  but 
was  always  able  to  reduce  it,  until  last  night  about  11 
o'clock,  when  it  became  strangulated,  and  caused  ex- 
treme pain.  Dr.  Uhler  was  called  to  see  him  in  the 
night.  Knowing  the  general  condition  of  the  patient, 
he  very  properly  declined  the  vigorous  treatment  some- 
times adopted.  He  gave  mild  injections,  one  dose  of 
calomel  and  opium,  and  applied  ice  to  the  tumour.  The 
patient  had  two  evacuations  per  anum  soon  after  the 
strangulation  took  place. 

The  tumour  was  on  the  left  side — not  very  large — 
it  scarcely  reached  into  the  scrotum.  The  spermatic 
cord  could  be  distinctly  felt  in  front  of  the  tumour. 

As  the  symptoms  oLstrangulation  were  very  clearly 
marked,  and  urgent,  it  was  my  decided  opinion,  and 
also  Dr.  Uhler's,  that  the  patient  would  be  subjected  to 
less  risk  from  the  operation  than  from  active  remedies, 
which  are  at  best  uncertain;  and  after  stating  the  case 
fairly  and  fully  to  himself  and  family,  and  giving  him 
an  opiate,  he  was  placed  on  the  table,  and  I  proceeded 
to  the  operation,  assisted  by  Dr.  Uhler  and  my  pupil 
Thomas,  now  Dr.  Yardley. 


FROM  INFLAMMATION.  59 

Several  small  vessels  were  divided  and  secured  in 
passing  through  the  integuments.  I  came  down  upon 
the  sac  in  the  usual  way,  and  distinctly  felt  a  fluid  un- 
der my  finger;  but  I  have  seldom  operated  on  a  case 
in  which  the  sac  was  so  much  thickened.  However,  I 
cautiously  opened  it,  and  brought  the  strangulated  part 
into  view.  It  was  intestine  highly  inflamed  and  par- 
tially covered  with  a  considerable  portion  of  fresh 
formed  lymph,  which  I  carefully  removed. 

I  felt  the  stricture  and  divided  it  cautiously,  with  the 
blunt-pointed  bistoury,  directly  upwards,  so  that  I 
passed  my  finger  by  the  side  of  the  bowel.  But,  at  this 
stage  of  the  operation,  I  was  assailed  by  unusual  diffi- 
culties in  consequence  of  the  universal  adhesion  of  the 
intestine  round  the  ring.  I  was  compelled  to  dilate 
more  largely  on  this  account,  and,  by  means  of  my 
finger,  1  detached  the  bowel  all  around,  and  endea- 
voured to  separate  the  adhesions  in  the  duplicature  of 
the  intestine  itself:  it  was  then  introduced  into  the 
cavity  of  the  abdomen.  Just  at  this  moment,  a  small 
quantity  of  yellow  serum  escaped  from  the  wound, 
which  we  concluded  was  a  dropsical  fluid.  The  patient 
was  returned  to  bed — his  head  was  raised  high,  a  large 
bolster,  doubled,  was  placed  under  his  hams,  and  he 
was  directed  barley-water,  &c. 

He  bore  the  operation  as  well  as  could  be  expected. 
As  he  seemed  inclined  to  sleep,  quietness  was  directed, 
and  the  attendants  were  ordered,  if  he  became  restless, 
to  give  him  thirty  drops  of  laudanum  every  six  hours. 

llth,  morning,  11  o'clock.  The  patient  has  passed 
an  easy  night;  has  had  some  singultus,  but  no  vomit- 
ing, and  has  passed  no  flatus.  His  abdomen  is  rather 
tender  on  pressure  but  is  not  tense.     Tongue  moist. 


60  DIFFICULTY  OF  REDUCTION 

and  slightly  furred.  Pulse  72,  full  and  soft.  Counte- 
nance natural.  Directed  ol.  ricini  5ss.  to  be  taken 
every  four  hours  until  the  bowels  are  opened;  also, 
tine,  opii  gtt.  xxx.  every  six  hours,  if  restless;  and  for 
diet,  barley-water,  rennet  whey,  molasses  and  water, 
&c. 

Evening,  7  o'clock.  The  patient  complains  of  con- 
siderable pain  in  the  abdomen.  He  has  taken  sij.  of 
the  oil,  without  having  any  evacuation.  No  flatus  has 
passed;  there  has  been  frequent  vomiting  and  singultus. 
There  is  no  tension  of  the  abdomen,  but  a  slight  sore- 
ness on  pressure.  Pulse  72,  rather  full  and  soft.  Tongue 
moist  and  very  little  furred.  Countenance  natural.  Di- 
rected ol.  ricini  ^ss.  every  three  hours,  with  occasional 
injections  of  flaxseed  tea.  Diet  and  drinks  continued 
as  before. 

12th,  morning,  10  o'clock.  The  patient  has  been  rest- 
less through  the  night,  although  he  has  taken  thirty 
drops  of  laudanum  every  six  hours.  He  has  taken  two 
ounces  of  castor  oil  since  I  last  saw  him,  and  has  re- 
ceived four  injections,  yet  there  has  been  no  discharge 
from  his  bowels,  either  of  feces  or  flatus.  Singultus 
continues  frequent.  The  abdomen  is  considerably  tense, 
and  sore  on  pressure,  wdth  a  burning  sensation  in  the 
bowels.  Pulse  80.  Tongue  moist,  and  very  little  furred. 
Countenance  good.  Vomiting  frequent.  Directed  one- 
fourth  of  a  Seidlitz  powder  to  be  taken  every  quarter 
of  an  hour,  and  the  injections  to  be  continued;  the 
laudanum  to  be  omitted,  and  the  same  diet  persevered 
in.  Evening,  6  o'clock.  The  patient  has  had  several 
discharges  from  the  bowels,  and  is  quite  relieved  of  the 
vomiting  and  singultus.  The  tension  of  the  abdomen 
has  subsided,  the  burning  sensation  has  ceased,  and  the 


FROM  INFLAMMATION.  61 

soreness  is  much  diminished.  He  has  passed  a  com- 
fortable afternoon.  Pulse  75,  and  natural.  Countenance 
natural,  composed.  Tongue  moist  and  nearly  clean. 
Directed  the  same  quantity  of  Seidlitz  powder  to  be 
taken  every  hour,  and  the  diet  to  be  continued. 

13th,  morning,  8  o'clock.  The  patient  has  rested 
comfortably  through  the  night,  and  has  had  two  dis- 
charges from  the  bowels.  Pulse,  tongue,  and  counte- 
nance natural.  He  is  in  every  respect  in  the  most 
favourable  condition.  Directed  the  Seidlitz  powder 
every  two  hours.  Diet  continued. 

14th,  morning,  11  o'clock.  The  patient  has  passed 
a  pleasant  night.  He  is  in  every  respect  free  from  any 
apparent  disease.  The  wound  has  nearly  healed  by  the 
first  intention.  There  is  no  suppuration  of  the  part. 
The  bowels  are  free.  Directed  the  Seidlitz  powder 
every  four  hours. 

15th,  12  o'clock.  The  patient's  bowels  have  been 
moved  freely  and  naturally.  He  remains  free  from  any 
unpleasant  symptom. 

This  patient  recovered,  although  he  had,  during  con- 
valescence, an  attack  of  intermittent  fever,  which  was 
then  prevalent  in  his  neighbourhood ;  but  he  had  ap- 
proached the  natural  limits  of  human  life,  and  died  a 
few  months  after  the  operation. 


Thickening  of  the  intestine,  and  an  effusion  of  lymph 
upon  its  surface  without  adhesions,  are  other  results  of 
inflammation  which  deserve  notice.  In  these  cases  it 
is  generally  necessary  to  enlarge  the  first  incision  at 
the  ring,  to  allow  the  bowel  to  pass  up.  The  lymph 
should  be  cautiously  removed  by  the  fingers  and  the 
handle  of  the  scalpel.   Cutting  instruments  should  be 


62  DIFFICULTY  OF  REDUCTION 

carefully  avoided  in  performing  this  part  of  the  opera- 
tion, as  in  the  following  case. 


CASE  VIII. 

Inguinal   Hernia — Strangulated,  dark,   and   injlamed 

Intestine. 

4thmo.  9th,  1821.  D.  W.,  a  man  of  colour,  about 
middle  age,  was  admitted  into  the  Pennsylvania  Hos- 
pital after  10  o'clock  at  night. 

He  had  been  subject  to  inguinal  hernia  on  the  right 
side  for  several  years,  and  strangulation  had  occasion- 
ally taken  place. 

On  this  occasion  the  bowel  had  been  strangulated, 
as  far  as  we  could  ascertain,  between  thirty-six  and 
forty-eight  hours.  The  strangulation  occurred  in  the 
act  of  vomiting. 

He  had  been  visited  this  afternoon  by  Dr.  Samuel 
Tucker,  who,  on  discovering  the  nature  of  the  case", 
called  on  me,  and  requested  me  to  take  charge  of  it. 
No  attempt  at  reduction  had  been  made.  When  exa- 
mined, the  tumour  was  found  rather  large,  and  some- 
what tender  to  the  touch.  There  was  but  little  tender- 
ness of  the  abdomen;  less,  (according  to  the  account 
given  by  the  patient,)  than  there  had  been  soon  after 
the  descent.  The  tongue  was  furred,  but  not  dark  co- 
loured. The  pulse  was  not  active  or  tense.  He  had  no 
stool  since  the  descent,  had  vomited  after  drinking,  but 
sometimes  retained  fluids  for  several  hours  on  his  sto- 
mach. 


FROM  INFLAMMATION.       '  63 

My  colleagues,  Drs.  Hartshorne  and  Hewson,  and 
my  friend  Dr.  Tucker,  consulted  on  the  case.  Some 
slight  attempts  were  made  at  the  taxis,  and  a  purgative 
enema  was  given,  which  operated  on  the  rectum.  But, 
after  stating  the  case  to  the  patient,  and  obtaining  his 
consent,  it  was  concluded  to  proceed  at  once  to  the 
operation.  Eighty  drops  of  laudanum  were  given,  and 
a  little  before  twelve  o'clock,  he  was  placed  on  the  ope- 
rating table. 

On  cutting  down  through  the  integuments  and  laying 
bare  the  sac,  it  appeared  to  be  distended  with  fluid. 
On  opening  it  in  my  usual  way,  with  the  forceps  and 
lancet,  a  bloody-coloured  fluid  issued  out.  I  now  en- 
larged the  orifice  freelv,  and  laid  bare  the  contents  of 
the  sac.  It  contained  a  portion  of  bowel,  without  omen- 
tum. The  intestine  was  very  dark  coloured^  but  there 
were  no  adhesions,  and  the  fluid  in  the  sac  ivas  desti- 
tute of  the  cadaverous  smell.  The  intestine,  moreover, 
was  much  thickened  by  inflammation,  and  was  coated 
with  a  large  portion  of  eflused  lymph,  particularly  at 
its  lower  and  most  dependent  part.  I  removed  a  part 
of  this  lymph  with  my  fingers  and  the  handle  of  the 
scalpel.  The  bowel  was  also  full  of  what  I  supposed  to 
be  liquid  feces.  The  stricture  was  at  the  abdominal 
ring.  I  divided  it,  in  part,  upward,  with  the  blunt- 
pointed  bistoury,  and  attempted  gently  to  introduce  the 
prolapsed  bowel,  as  1  w  as  desirous  of  avoiding  any  un- 
necessary enlargement  of  the  ring.  But  as  I  was  still 
more  anxious  to  avoid  any  violence  to  the  intestine  in 
its  inflamed  state,  I  was  under  the  necessity  of  enlarg- 
ing the  opening  with  the  bistoury,  and  I  then  returned 
the  bowel. 

The  patient  was  placed  on  his  back  in  bed,  with  his 


64  •symptoms  of  stragulation 

knees  elevated,  and  a  pillow  under  his  hams;  the  wound 
being  previously  drawn  together  by  three  stitches  of 
the  interrupted  suture,  and  adhesive  strips.  He  was 
directed  to  take  barley-water,  &c. 

10th,  mor7iing.  The  House-Surgeon  sat  up  with  the 
patient,  and  reports  that  he  passed  a  most  excellent 
night,  and  slept  very  well.  I  found  him  better  than  I 
had  reason  to  anticipate.  His  tongue  is  yet  coated 
with  considerable  yellow  fur.  His  pulse  remarkably 
tranquil,  considering  all  the  circumstances.  Directed 
a  table-spoonful  of  castor  oil  every  three  hours  until  the 
bowels  are  opened. 

This  patient  recovered  completely  in  a  short  time. 


SECTION  VI. 


SYMPTOMS  OF  STRANGULATION  AFTER  REDUCTION  BY  TAXIS. 

In  the  section  on  the  propriety  of  opening  the  her- 
nial sac,  cases  have  been  referred  to,  in  which  symp- 
toms of  strangulation  continued  after  reduction,  and 
terminated  in  the  death  of  the  patient.  The  issue  of 
these  cases  is  ascribed  to  mechanical  obstruction  within 
the  sac,  from  a  stricture  at  its  neck,  entanglement  of 
the  omentum  around  the  bowel,  &c. 

It  is  now  intended  to  show,  that  a  train  of  the  most 
alarming  symptoms  may  continue  for  days  after  reduc- 
tion, and  yet  may  yield  to  appropriate  medical  treat- 
ment. 

The  remedy  upon  which  I  have  placed  chief  reliance 
in  these  cases  is  mercury,  introduced  into  the  system 


AFTER  REDUCTION  BY  TAXIS.  65 

in  extremely  minute  portions.  Calomel,  in  the  dose  of 
one  quarter  or  one  sixth  of  a  grain,  given  every  one 
or  two  hours,  is  the  form  I  would  recommend. 

The  efficacy  of  mercury  administered  according  to 
this  method,  has  been  tested  by  ample  experience  in  the 
treatment  of  many  diseases.  Dr.  Ayre,  in  his  work  on 
Marasmus,  has  thrown  much  light  on  this  practice ;  and 
the  former  Dr.  Edward  Miller,  of  New  York,  who  died 
in  1791,  has  strongly  recommended  the  practice  in  an 
essay  entitled  "  Remarks  on  the  Cholera  and  Bilious 
Diarrhoea  of  Infants."  It  is  now  much  employed  by 
many  physicians  of  Philadelphia,  and  is  found  appli- 
cable to  a  great  variety  of  diseases  in  which  calomel 
was  formerly  employed  in  larger  doses. 

I  have  carried  out  this  practice  to  the  treatment  of 
certain  cases  of  strangulated  hernia,  with  obvious  ad- 
vantage. 

I  shall  not  attempt  to  discuss  at  large  the  modus  ope- 
randi of  this  remedy.  It  is  well  known  that  calomel, 
even  in  very  small  portions,  has  the  power  of  correct- 
ing functional  derangement  of  the  liver,  and  of  exciting 
the  flow  of  yellow,  healthy  bile.  That  bile  of  this  de- 
scription is  the  most  natural  excitant  of  the  bowels, 
and  is  admirably  calculated  to  promote  steady  and 
healthful  peristaltic  action,  it  is  presumed  will  be  ge- 
nerally admitted. 

The  introduction  of  calomel  in  such  minute  portions  as 
not  to  offend  the  stomach,  or  to  produce  any  constitu- 
tional irritation,  is  peculiarly  appropriate  in  diseases 
where  the  stomach  is  irritable,  and  in  none  more  so  than 
in  strangulated  hernia.  Large  doses  of  calomel  excite  the 
liver  and  alimentary  canal  to  increased  action,  and  thus 

9 


66  SYMPTOMS  OF  STRANGULATION 

transcend  that  medium  which  it  is  so  desirable  to  main- 
tain: hence,  while  powerful  doses  are  obviously  injurious 
in  cases  of  recent  strangulation,  the  accumulated  effect 
of  minute  portions,  frequently  repeated,  may  be  attained; 
while  at  the  same  time  the  irritability  of  the  stomach 
is  allayed. 

The  following  cases  will  illustrate  the  beneficial  effects 
of  this  practice. 


CASE  IX. 

Hernia — Reduction  by  Taxis — Symptoms  continued — 
Stercoracious  Vomiting — Recovery. 

9th  mo.  18th,  1835.  Was  called  about  12  o'clock,  M. 
to  see  J.  L.,  a  respectable  old  gentleman  residing  in 
Green  street,  in  consultation  with  Dr.  Janney.  The 
patient  is  a  tall,  spare  man,  of  delicate  constitution, 
aged  about  sixty-eight  j'^ears.  He  had  been  afflicted 
with  inguinal  hernia  of  the  left  side,  for  between 
forty  and  fifty  years,  during  which  time  he  had  worn  a 
truss.  Within  the  past  few  years,  he  has  had  several 
attacks  of  strangulation.  Dr.  Janney  has  attended 
him,  and  has  succeeded  in  reducing  the  parts  by  taxis, 
after  venesection  and  a  full  dose  of  opium. 

The  present  attack  commenced  on  the  night  of  the 
13th  inst.;  he  awoke  from  sleep,  complaining  of  pain  in 
the  groin,  and  discovered  that  the  hernia  was  strangu- 
lated. He  went  down  stairs  for  the  purpose  of  giving 
himself  an  injection,  and  just  before  receiving  it,  had  a 
discharge  from  his  bowels,  in  the  privy,  without  produc- 
ing any  change  in  the  tumour. 


AFTER  REDUCTION  BY  TAXIS.  67 

He  then  took  grs.  ij.  of  sulp.  morph.  which  com- 
posed him  for  the  night,  and  early  the  next  morning  he 
was  enabled  to  reduce  the  bowel.  The  symptoms  of 
strangulation,  pain  in  the  abdomen,  vomiting,  &c.  still 
continued,  and  on  the  15th  Dr.  Janney  was  called.  He 
found  the  patient  affected  with  copious  mucous  vomit- 
ing, obstinate  constipation,  tympanitic  and  tender  ab- 
domen. On  examining  the  groin,  he  could  readily  pass 
the  index  finger  through  the  internal  ring,  and  there  was 
not  the  slightest  appearance  of  a  tumour  externally,  so 
that  he  was  convinced  that  the  parts  were  returned. 
He  directed  v.s. — and  calomel  gr.  ss.  every  hour,  with 
carb.sod8e,and  aqua  menth.  On  the  16th,  the  calomel  was 
suspended  for  a  short  time,  and  calcined  magnesia  di- 
rected in  small  and  frequent  doses;  this  was  rejected  by 
the  stomach ;  ol.  ricini  was  also  tried,  but  was  vomited 
up ;  the  calomel  was  then  resumed,  and  injections  of 
salt  and  flaxseed  tea  were  given  every  three  hours. 

On  the  17th  he  was  attacked  with  stercoracious  vo- 
miting; the  abdomen  was  tender  to  the  touch;  the 
bowels,  constipated.  The  calomel  had  been  continued. 
He  was  cupped  on  the  abdomen,  and  bled  from  the  arm 
with  relief — blood  not  sizy.  The  Doctor  remarked  that 
the  vomiting  was  first,  mucous;  secondly,  dark-green; 
thirdly,  brown ;  and  fourthly,  decidedly  stercoracious. 

On  the  18th,  I  saw  the  patient  in  consultation.  His 
bowels  were  still  confined,  nothing  having  passed  since 
the  night  of  the  13th;  the  stomach  very  irritable,  he  vo- 
mited stercoracious  matter  twice  while  we  were  in  the 
room;  pulse  112  in  the  minute,  and  irregular;  tongue 
brown  and  moist;  abdomen  slightly  tympanitic,  and 
bears  pressure  very  well.  I  could  readily  pass  my  finger 
up  to  the  internal  ring,  the  spermatic  cord  evident; 


68  SYMPTOMS  OF  STRANGULATION 

skin  warm  and  natural ;  respiration  easy ;  countenance 
not  distressed;  position  in  bed  natural.  Directed  a 
strong  decoction  of  senna  to  be  given  as  an  enema 
every  three  hours,  and  a  poultice  of  stramonium  leaves 
to  the  abdomen. 

Evening.  One  discharge  followed  injection ;  it  was 
not  preserved,  but  probably  consisted  of  injecting  mat- 
ter only ;  ring  still  more  relaxed ;  vomited  but  once 
since  our  last  visit.  Directed  calomel  powder  gr.  4  each, 
one  to  be  taken  every  hour ;  and  an  injection  of  jalap 
5J.  to  a  pint  of  water,  every  three  hours.  Stramonium 
leaves  continued. 

19th.  Bowels  have  not  been  moved;  sleep  light  and 
disturbed ;  vomiting  less  frequent,  but  still  stercoracious; 
pulse  135,  and  feeble;  skin  warm;  tongue  brown,  moist, 
and  mucous,  resembling  very  much  the  mucous  tongue 
in  typhus  fever,  which  I  have  always  found  to  be  asso- 
ciated with  great  danger ;  abdomen  slightly  tympani- 
tic, abdominal  muscles  seemed  relaxed,  the  folds  of  the 
intestines  can  be  distinctly  traced  underneath  the  mus- 
cles ;  ring  still  more  dilated,  the  finger  can  be  passed 
an  inch  within  the  abdomen.  Has  taken  calomel 
powders  regularly  through  the  night,  and  at  his  own 
request,  has  been  placed  in  a  warm  bath ;  has  had  three 
injections  of  jalap,  without  effect.  Same  treatment  con- 
tinued, with  the  addition  of  a  powerful  injection  to  be 
thrown  in  through  a  tube  passed  beyond  the  sigmoid 
flexure  of  the  colon. 

Evening.  Dr.  Janney  and  my  son  succeeded  in  pass- 
ing a  large  gum  elastic  tube  about  thirteen  inches  up  the 
bowel,  through  which  ^iij.  of  jalap,  suspended  in  a  large 
quantity  of  flaxseed  tea,  was  injected.  During  their 
visit,  about  12  o'clock,  the  hernia  descended  into  the 
sac,  and  was  readily  returned.  Has  passed  several  por- 


AFTER  REDUCTION  BY  TAXIS.  69 

tions  of  the  injection  without  foeccs,  stercoracious  vo- 
miting continues,  pulse  112.  He  says  there  is  a  sHght 
rumbling  in  the  bowels,  and  that  he  feels  rather  better. 
Continued  small  doses  of  calomel,  and  poultice  of  stra- 
monium leaves. 

20th.  Patient  thinks  that  he  cast  up  the  fluids  which 
have  been  injected  per  anum;  says  he  has  passed  flatus, 
and  believes  his  bowels  have  been  moved ;  has  had  se- 
veral dark-coloured  evacuations,  which  we  suspected  to 
be  nothing  more  than  coloured  mucus.  Stercora- 
cious  vomiting  continues  unabated;  pulse  128;  skin 
warm;  slept  at  intervals  through  the  night;  says  he  feels 
rather  more  comfortable ;  rises  from  bed  with  ease ; 
slight  tenderness  of  the  abdomen.  Calomel  powders 
continued.  Directed  warm  bath,  an  injection  containing 
ten  drops  of  croton  oil  into  the  rectum,  and  another 
injection  of  jalap  by  the  tube  into  the  colon. 

Evening.  Has  had  no  discharge,  though  there  is  evi- 
dently more  motion  in  the  bowels,  pulse  120,  expression 
of  countenance  more  lively ;  has  taken  portions  of 
chicken-water  through  the  day,  which  he  relished; 
asked  for  boiled  meat ;  thinks  his  strength  is  improv- 
ing. Had  an  injection  into  the  colon  of  Sss.  of  jalap 
suspended  in  mucilage.  Continue  powders.  Directed 
an  anodyne  enema  at  bed  time. 

21st.  Patient  much  better.  We  were  informed  that 
soon  after  we  left  him  on  the  preceding  evening,  he  had  a 
copious  bilious  discharge,  which  was  preceded  by  con- 
siderable rumbling  in  the  bowels,  and  was  followed  by 
several  more  in  the  course  of  the  night.  We  inspected 
the  discharges,  and  were  fully  satisfied  that  they  were 
feculent.  Has  had  no  vomiting  since  the  bowels  were 
opened,  slight  ptyalism  was  observable,  pulse  calm  and 


70  SYMPTOMS  OF  STRANGULATION 

natural,  tongue  moist  and  brown,  probably  coloured  by 
tobacco,  which  he  has  been  chewing  this  morning  for 
the  first  time  during  his  illness  ;  has  no  pain,  feels  an 
appetite.  He  took  an  anodyne  enema,  and  slept  com- 
fortably through  the  night.  We  suspended  medicine, 
and  directed  mild  nutritious  drinks. 

22d.  Still  improving — had  a  copious  stool  in  the 
course  of  yesterday,  and  one  this  morning;  abdomen 
perfectly  flaccid;  suffers  no  pain;  dressed  himself  and 
went  down  stairs  yesterday;  ring  contracted  to  its 
usual  dimensions.  Directed  a  tea-spoonful  of  magnes. 
calc.  every  three  hours  until  it  operates. 

23d.  Medicine  has  operated  several  times,  feels  quite 
well,  except  that  he  is  weak.  Convalescent. 

27th.  Feels  himself  quite  well,  is  dressed  and  walk- 
ing about,  and  has  resumed  his  usual  habits. 

RemarJcs. 

This  case  affords  ample  room  for  reflection  and  re- 
mark. In  it  we.  are  presented  with  a  train  of  the  most 
dangerous  syhiptoms,  especially  stercoracious  vomit- 
ing, which  continued  for  several  days ;  and  though  the 
patient  was  an  old  man  of  delicate  constitution,  yet  he 
finally  recovered. 

In  reviewing  the  practice  pursued,  I  am  disposed  to 
believe,  that  the  minute  doses  of  calomel  had  an  im- 
portant agency  in  the  cure. 

The  steady  application  of  stramonium  leaves  over 
the  whole  abdomen,  combined  with  the  use  of  powerful 
injections,  as  used  in  a  case  reported  by  Dr.  Condie, 
hereafter  to  be  detailed,  although  it  is  derived  from  an 
"  African  colic  doctor,"  is  rational  and  worthy  of  imi- 
tation. Every  practitioner  is  familiar  with  the  dilating 


AFTER  REDUCTION  BY  TAXIS.  71 

power  of  the  extract  of  stramonium  over  the  iris,  and 
in  this  case  the  poultice  certainly  did  appear  to  dilate 
the  abdominal  rinor. 

It  will  be  noticed,  that  this  patient  had  been  re- 
lieved several  times  from  strangulated  bowel,  by  exhi-, 
biting  a  large  dose  of  opium  after  the  use  of  the  lancet. 
Dr.  Janney  has  related  to  me  several  instances  of  re- 
markable success  from  this  plan,  which  has  occurred  in 
his  practice.  He  administers  from  3  to  4  grs.  of  opium 
at  one  dose,  and  considers  it  very  important  that  a  large 
dose  should  be  given  at  a  time,  instead  of  giving  it  in 
small  portions,  as  is  frequently  done.  Should  a  fair  case 
of  recent  strangulation  present  itself,  I  should  pursue 
this  course,  with  the  addition  of  a  poultice  of  stramo- 
nium leaves,  before  proceeding  to  the  operation. 

The  following  case,  which  has  been  kindly  furnished 
me  by  Dr.  J.  Rodman  Paul,  bears  a  striking  analogy 
to  the  preceding. 


CASE  X. 


On  the  12th  of  November,  1833,  Dr.  Neill  requested 
me  to  accompany  him  to  visit  Mr.  Steinhaur,  a  baker, 
residing  in  South  Second  street,  who  was  labouring 
under  strangulated  inguinal  hernia  of  the  right  side. 
Various  means  for  its  reduction  had  been  resorted  to 
without  success,  and  the  pain  which  the  patient  expe- 
rienced, together  with  the  incessant  vomiting,  induced 
us  to  propose  an  immediate  performance  of  an  opera- 
tion, should  another  effort  of  taxis  prove  unavailing. 
Fortunately,  in  this  attempt  we  succeeded;  the  bowel 


72  SYMPTOMS  OF  STRANGULATION 

was  returned,  and  we  were  enabled  to  push  the  finger 
covered  by  integument,  through  the  abdominal  canal 
and  rings  into  the  cavity  of  the  abdomen.  In  this  con- 
dition we  left  him,  auguring  a  diflerent  state  of  things 
^at  our  next  visit.  But  we  were  disappointed,  the  vomit- 
ing continued,  and  the  bowels  remained  obstinately 
constipated ;  purgatives  were  either  rejected  or  pro- 
duced no  effect;  injections  into  the  colon  through  a 
gum  elastic  tube  were  attended  by  no  better  result. 
This  case  reminded  me  strongly  of  one  that  came  under 
my  care  when  a  resident  at  the  Pennsylvania  Hospital. 
It  was  that  of  a  coloured  man  who  was  operated  on  for 
strangulated  hernia  by  Dr.  Parrish,  and  in  which  the 
symptoms  continued  unrelieved  after  the  operation,  until 
the  gums  were  touched  by  the  use  of  small  doses  of 
calomel.  The  same  plan  was  now  pursued  in  Stein- 
haur's  case,  and  with  the  same  happy  result;  for  as  soon 
as  the  peculiar  effect  of  the  mercury  was  produced,  the 
constipation  yielded,  and  the  vomiting  ceased,  it  being 
ten  days  from  the  commencement  of  the  attack. 


SECTION  VII. 


SYMPTOMS  OP  STRANGULATION  AFTER  OPERATION. 

Even  after  the  surgeon  has  performed  the  operation 
for  strangulated  hernia  to  his  entire  satisfaction,  he 
sometimes  meets  with  disappointment.  The  contents 
of  the  sac  may  be  exposed,  and  may  present  a  promis- 
ing appearance,  the  stricture  may  be  liberated,  and 
the  parts  returned  without  difficulty  into  the  abdo- 


AFTER  OPERATION.  73 

men,  yet  day  after  day  may  pass  over,  without  any  im- 
provement in  the  condition  of  the  patient.  From  some 
unknown  cause  the  obstruction  in  the  bowels  is  kept 
up,  and  death  is  threatened  if  rehef  is  not  afforded. 

The  following  case  affords  a  striking  instance  of 
this  kind: 


CASE  XI. 

Scrotal  Hernia — Symptoms  of  Strangulation  after  opera- 

iio7i — Cure, 

ll//i  mo.  12th,  1825.  W.  C,  an  old  coloured  man, 
was  admitted  this  morning  into  the  Pennsylvania  Hos- 
pital. He  has  been  afflicted  for  many  years  with  a  large 
scrotal  hernia  of  the  right  side,  and  has  had  several 
attacks  of  strangulation,  but  the  parts  have  always 
been  returned  without  an  operation.  About  11  o'clock 
last  night  the  hernia  became  again  strangulated. 

On  the  present  occasion,  the  warm  bath,  the  tobacco 
injection,  bleeding  ad  deliquium,  cold  applications,  &c. 
were  tried  without  effect.  An  opiate  was  then  given, 
the  operation  was  proposed,  and  the  patient  con- 
sented.' 

His  stomach  was  irritable,  and  he  vomited  violently 
as  he  was  carried  to  the  operating  room.  His  abdo- 
men was  very  tumid  and  tender  to  the  touch,  as  was 
also  the  tumour.  About  8  o'clock  in  the  evening,  assisted 
by  my  friend  and  colleague  Dr.  Hewson,  and  in  the  pre- 
sence of  the  class  of  students,  and  many  professional 
visitors,  I  proceeded  to  the  operation ;  the  patient  hav- 
ing previously  taken  three  grains  of  opium. 

10 


74  SYMPTOMS  OF  STRANGULATION 

I  made  a  free  incision,  commencing  above  the  exter- 
nal ring,  and  extending  nearly  to  the  bottom  of  the  scro- 
tmn,  then  dissected  down  to  the  sac,  and  laid  it  open  in 
the  usual  manner.  At  the  external  ring  a  firm  stricture 
was  detected,  which  was  carefully  divided  with  the 
blunt  bistoury,  until  T  could  pass  the  finger  by  the  side 
of  the  bowel  into  the  abdomen. 

Just  at  this  moment  a  most  unpleasant  circumstance 
occurred — the  patient  w  as  seized  with  violent  vomiting. 
Notwithstanding  my  eflforts  to  prevent  it,  a  portion  of 
intestine  considerably  larger  than  that  which  was  in- 
volved in  the  stricture,  was  forced  out  of  the  abdomen. 
The  straining  and  violent  bearing-down  efforts  were 
such,  that  I  could  not  return  the  parts  until  I  had  di- 
lated the  ring  more  freely ;  even  then  it  was  with  the 
greatest  difficulty  that  I  succeeded  at  all.  After  the 
reduction,  a  branch  of  the  external  pudic  artery,  which 
bled  considerably,  was  secured  by  a  ligature. 

The  patient  complained  greatly  during  the  operation, 
and  on  every  attempt  at  reduction,  he  cried  out,  re- 
ferring the  pain  to  the  umbilicus. 

The  dressing  being  completed,  he  was  placed  in  bed 
with  his  limbs  supported  on  the  angular  box  and  pil- 
low. The  belly  continued  tense,  painful  on  pressure, 
hard,  and  tympanitic.  He  took  two  grains  of  opium  at 
half  past  9  o'clock,  one  grain  at  half  past  12,  and  an- 
other at  about  three  in  the  morning ;  the  last  was  re- 
jected. He  was  ordered  to  take  no  other  drink  or 
nutriment  than  barley-water  acidulated  with  lemon- 
juice. 

13th.  The  patient  had  several  slight  attacks  of  hiccough 
after  the  operation,  but  has  passed  a  quiet  night,  dozing 
frequently.  Pulse  80,  skin  nearly  natural,  tongue  furred; 


AFTER  OPERATION.  75 

he  has  passed  neither  flatus  nor  feces.  He  complains, 
occasionally,  of  a  sharp  pain  around  the  umbilicus. 
The  abdomen  is  still  tense  and  tympanitic.  Ordered 
ol.  ricini  3ss.  every  two  hours  until  purged  ;  also  opii. 
gr.  j.  every  four  hours,  if  restless.  Regimen  continued. 
Evening.  Pulse  80,  full  and  soft ;  abdomen  less  tender 
to  the  touch ;  stomach  retentive.  The  patient  is  dis- 
posed to  sleep.  He  has  occasionally  very  slight  singul- 
tus. He  has  taken  about  an  ounce  of  the  oil,  but  seems 
to  suffer  for  want  of  a  free  discharge  from  the  bowels. 
An  injection  afforded  partial  relief  Dr.  Parrish  or- 
dered injections  of  warm  w  ater  to  be  thrown  up  through 
a  large  flexible  catheter,  and  some  fecal  matter  and 
flatus  were  thus  brought  away.  Dry  syringing  with 
the  same  instrument  was  then  employed,  with  some  re- 
hef  to  the  flatulent  distension.  He  has  passed  his  urine 
freely.  Ordered  to  continue  the  oil,  and  also  the  dry 
syringing,  if  necessary. 

14th.  The  patient  took  last  night  a  dose  of  opium, 
in  consequence  of  pain  in  the  abdomen,  and  not  being 
relieved,  warm  fomentations  were  applied.  The  abdo- 
men is  still  tense  and  tender ;  pulse  80 ;  tongue  furred 
and  moist.  He  seems  disposed  to  doze ;  some  flatus 
has  been  passed  this  morning.  Ordered  injections  of 
strong  senna  tea,  the  castor  oil  being  continued ;  and 
if  these  should  fail  to  operate  on  the  bowels,  croton  oil 
gtt.  ss.  to  be  given  every  hour,  until  four  drops  be 
taken. — Evening.  His  condition  remains  much  the 
same.  No  evacuation  has  taken  place.  His  stomach 
is  retentive,  but  he  has  frequent  eructations.  Ordered 
to  continue  the  same  remedies.  The  croton  oil  increased 
to  gtt.  ss.  every  two  hours.  An  opiate  to  be  exhibited 
when  the  patient  is  restless. 


76  SYMPTOMS  OF  STRANGULATION 

15th.  Pulse  80;  skin  natural;  tongue  moist, furred, 
and  rather  more  yellow ;  countenance  depressed ; 
spirits  low ;  abdomen  very  tense  and  tympanitic.  The 
patient  has  passed  a  little  flatus  without  the  tube,  but 
has  had  no  stool.  A  dose  of  terebinthinate  mixture  was 
exhibited,  but  the  stomach  rejected  it  immediately. 
Ordered  one-fourth  of  a  grain  of  calomel  to  be  taken 
every  half  hour ;  fomentation  of  spirits  of  turpentine 
to  the  abdomen  ;  and,  if  restless,  injections  of  assafcE- 
tida,  each  containing  a  drachm  of  laudanum ;  also 
directed  to  drink  chicken-water. — Evening,  His  con- 
dition continues  the  same,  except  that  there  is  more 
tenderness  of  the  abdomen.  Ordered  the  calomel  to  be 
given  in  the  dose  of  one  or  two  grains  every  hour  if  the 
stomach  will  retain  it.  If  not  relieved,  a  hot  brick  and 
spirits  of  turpentine  to  be  applied  to  the  abdomen.  Ano- 
dyne enemata  to  be  given  if  required. 

16th.  Pulse  80;  abdomen  less  tense  and  tender; 
tongue  furred  and  moist ;  temperature  of  the  skin  natu- 
ral. The  patient  has  taken,  in  divided  doses,  about 
twenty-five  grains  of  calomel  without  effect.  He  has 
had  singultus  during  the  night  and  morning.  An  ano- 
dyne enema  and  the  stimulating  fomentations  have 
partially  relieved  his  hiccough.  Treatment  continued. 
Evening.  Pulse  68,  full,  round,  and  soft.  Abdomen  tym- 
panitic, but  less  tender.  The  singultus  continues,  but 
the  patient  says  he  feels  more  comfortable  than  at  any 
other  time  since  the  operation.  There  has  been  no  fecal 
discharo^e.  Ordered  to  continue  the  calomel,  and  if 
much  pain  occurs,  the  anodyne  enema. 

17th.  Early  in  the  morning,  the  patient  complained 
of  occasional  violent  pains,  beginning  in  the  wound 
and  extending  all  over  the  body,  up  to  the  throat.  The 


AFTER  OPERATION.  77 

pain  about  the  Avound  was  as  severe  as  before  the  ope- 
ration. Half  past  9  o'clock — pulse  80,  full,  round  and 
rather  tense ;  temperature  of  the  skin  increased ;  pain 
still  sreat ;  sinaultus  continues ;  abdomen  less  tense. 
As  the  pain  appeared  to  increase  with  the  vascular  ex- 
citement, Dr.  Parrish  ordered  him  bled  to  the  amount 
of  twelve  ounces.  Ordered  also  the  warm  bath,  and 
occasional  purgative  enemata.  The  anodyne  injec- 
tions, and  the  calomel  to  be  continued. — 12  o"^ clock. 
Pulse  84 ;  tongue  and  skin  unaltered;  he  has  been  in  the 
warm  bath  fifteen  minutes  ;  again  bled  to  the  amount 
of  sixteen  ounces. — Evening.  Tongue  still  moist ;  pulse 
88,  firm,  and  full ;  singultus  continues ;  the  w^arm  bath 
has  been  repeated ;  this,  and  the  venesection  have  given 
him  much  relief.     Treatment  continued. 

18th.  The  patient  has  passed  a  tolerably  good  night ; 
free  from  pain,  though  much  troubled  with  singultus ; 
the  warm  bath  was  repeated  at  9  o'clock  last  evening 
with  great  benefit ;  pulse  84,  furred  and  moist ;  skin 
natural ;  fulness  and  tension  of  the  abdomen  diminished, 
and  no  pain  felt  on  pressure.  He  says  he  is  much  re- 
heved,  but  has  had  no  fecal  discharge  ;  flatus  is  passed 
occasionally ;  ordered  to  omit  the  calomel.  R.  pulv. 
jalap,  oi.  supertart.  potass  ^ij.  m.  div.  in  pulv.  no.  6. 
One  of  these  powders  to  be  given  every  hour,  in  sweet- 
ened mint-water. — Evening.  The  patient  has  been 
once  in  the  warm  bath,  and  has  taken  four  powders ; 
pulse  80.  His  condition  remains,  in  other  respects  the 
same  ;  ordered  to  continue  the  powders,  and  the  ano- 
dyne injections  when  necessary. 

19th.  Pulse  72,  nearly  natural ;  skin  natural ;  tongue 
furred  and  moist ;  abdomen  as  yesterday  ;  constipation 
and  singultus  continue  j  vomiting  frequent  in  the  night ; 


78  SYMPTOMS  OF  STRANGULATION 

the  calomel  was  resumed  this  morning ;  countenance 
good ;  ordered  to  continue  the  calomel  and  occasional 
warm  bath ;  mutton  broth  directed  for  his  diet. — Even- 
ing. The  patient  feels  a  little  better :  in  other  respects 
his  condition  remains  the  same.  He  has  partaken 
freely  of  his  mutton  broth,  which  he  enjoyed  much. 
Treatment  continued. 

20th.  Pulse  78 ;  tongue  less  furred,  quite  moist,  and 
somewhat  redder ;  gums  more  tumid ;  abdomen  still 
tense  but  softer ;  singultus  abated ;  countenance  and 
spirits  good.  The  patient  discharged  flatus  several 
times,  but  no  feces ;  he  rehshes,  and  desires  food. — 
Treatment  continued. — Evening.  Pulse  72 ;  a  good 
deal  of  flatus  has  been  passed,  and  the  patient  is  dis- 
posed to  renew  his  old  habit  of  chewing  tobacco. 
Treatment  continued. 

21st.  The  patient  has  had  several  fecal  discharges. 
Pulse  64  and  soft ;  gums  slightly  sore;  abdomen  greatly 
diminished,  and  its  uneasiness  relieved  ;  singultus  still 
occurs  occasionally.  The  first  alvine  discharge  took 
place  last  night  about  10  o'clock ;  he  then  began  to 
take  sulphate  of  magnesia  §ss.  every  three  hours ;  or- 
dered to  omit  the  calomel  and  continue  the  salts. — 
Evening.  He  has  had  four  evacuations  since  morning ; 
some  singultus  continues.  Every  appearance  is  fav- 
ourable. 

22d.  Pulse  64,  full  and  soft ;  abdomen  becoming  soft 
and  natural ;  appetite  good ;  the  patient  has  had  free 
discharges  from  the  bowels ;  there  is  still  a  little  sin- 
gultus. The  sac  and  neighbouring  integuments  are 
very  considerably  thickened  by  inflammation,  which  ex- 
tends along  the  whole  length  of  the  incision. 

From  this  date  the  patient  was  regularly  convales- 


AFTER  OPERATION.  79 

cent,  suffering  little  except  from  singultus,  which  was 
relieved  by  anodyne  enemata  containing  a  portion  of 
the  oil  of  amber,  and  the  musk  julep,  administered  in  the 
proportion  of  five  grains  of  musk  in  each  dose.  He 
was  discharged  in  good  health,  on  the  thirtieth  of  the 
month ;  the  cicatrization  of  the  wound  being  nearly 
completed.^ 


* 


*  It  will  be  perceived  that  the  preceding  case  is  unusually  interesting. 
The  patient  was  in  extreme  danger,  and  eight  days  elapsed  after  the  opera- 
tion before  the  bowels  were  opened.  Its  details  may  be  regarded  as  pro- 
lix, but  I  have  deemed  it  proper  to  give  it  in  its  present  form  as  it  was  re- 
ported at  the  time  by  my  former  pupil  Dr,  J.  Rodman  Paul.  He  was  then 
house  Surgeon  in  the  Pennsylvania  Hospital  ;  his  humane  and  unremitted 
exertions  in  the  case  of  a  very  humble,  yet  truly  deserving  man,  while  it 
merited  and  received  my  warm  approbation,  has  been,  I  doubt  not,  amply 
rewarded  by  the  consciousness  of  having  discharged  his  duty. 


CHAPTER  III. 

DIAGNOSIS  OF  MORTIFICATION. 


SECTION  I. 


ON   THE  CONSTITUTIONAL  EVIDENCES  OF  MORTIFIED   BOWEL. 

It  is  deemed  a  point  of  great  importance  amongst 
surgeons  to  have  some  unequivocal  evidence,  of  the 
existence  of  mortification  in  a  strangulated  bowel,  be- 
fore it  is  exposed  by  an  operation.  It  is  highly 
desirable,  in  forming  an  opinion  of  the  probable  result 
of  a  case,  in  which  an  operation  is  proposed,  that  the 
surgeon  should  present  to  the  patient  and  his  friends, 
a  full  and  candid  view  of  the  whole  subject.  If  there 
is  ground  for  the  belief  that  the  incarcerated  parts,  or 
a  portion  of  them,  are  actually  dead,  the  prospect  of  a 
successful  issue  is  necessarily  limited ;  hence,  it  be- 
comes very  important  to  estimate  the  value  of  those 
signs  which  are  laid  down  for  our  guidance  in  these 
cases,  and  to  be  cautious  in  pronouncing  a  positive 
opinion.  To  hold  out  a  flattering  prospect  of  success 
when  it  cannot  be  founded  on  a  proper  share  of  rea- 
sonable evidence,  I  consider  radically  wrong.  The 
symptoms  denoting  mortification  of  the  bowel,  as  com- 
monly detailed  in  systematic  works,  are  not  in  my  judg- 
ment sufficient  to  establish  the  fact. 


CONSTITUTIONAL  EVIDENCES  OF  MORTIFIED  BOWEL       81 

Thus,  we  are  taught  to  beheve  that  when  the  bowel 
becomes  mortified,  the  pain  ceases ;  the  pulse  which 
has  been  active,  is  feeble  and  creeping;  clammy 
sweats  and  a  death-like  coldness  pervade  the  sur- 
face ;  the  countenance  becomes  hippocratic ;  singultus 
and  stercoracious  vomiting  are  generally  present,  and 
the  patient  dies  with  the  intellect  perfectly  clear. 

That  these  symptoms  are  present  in  a  large  majority 
of  cases  in  which  mortification  of  the  bowel  has  taken 
place,  experience  amply  shows ;  I  have,  however,  seen 
cases  in  which  extensive  mortification  has  existed 
without  the  occurrence  of  these  symptoms,  and  others 
in  which  the  usual  symptoms  of  mortification  were 
present  without  the  bowel  being  actually  dead,  as  has 
appeared  on  the  performance  of  the  operation. 

As  an  example  of  the  former  condition,  I  will  state 
the  following  cases : 


CASE  XII. 

Strangulated  Scrotal  Hernia — Gangrene — Death. 

Itli.  7no.  14th,  1814.  A  mulatto  man  who  appeared 
to  be  about  thirty  years  of  age,  was  admitted  into  the 
Philadelphia  Almshouse  on  the  evening  of  this  day, 
with  strangulated  scrotal  hernia. 

15th.  I  visited  him  in  the  morning,  and  called  a  con- 
sultation on  the  case,  as  the  usual  remedies  for  reduc- 
tion had  been  tried  in  vain.  The  operation  was  per- 
formed in  the  afternoon,  being  three  days  after  the 
commencement  of  strangulation ;  the  patient  had  not 

had    a   stool  from  the  time  of  the  accident.     Just 
11 


82  CONSTITUTIONAL  EVIDENCES 

before  the  operation,  the  condition  of  his  pulse,  skin, 
and  tongue  was  such  as  would  not  have  induced  the 
suspicion  of  gangrene ;  his  abdomen  was  tumid  and 
painful  to  the  touch.  He  had  some  hiccough  and 
vomiting. 

I  operated  in  consultation  with  my  medical  friends, 
Drs.  James,  Hewson,  Hartshorne,  Chapman,  and  Stew- 
art. No  difficulty  presented  in  the  course  of  the  ope- 
ration, but  in  laying  open  the  hernial  sac,  it  was  found 
that  a  portion  of  intestine  only,  was  contained  in  it, 
and  the  most  depending  part  of  the  bowel  was  morti- 
fied for  the  space  of  about  half  an  inch  in  width  and 
two  inches  in  length.  The  stricture  was  at  the  ab- 
domnial  ring,  and  embraced  the  bowel  very  closely ;  it 
was  divided  with  the  blunt-pointed  bistoury,  and  the  in- 
testine left  in  the  wound.  We  directed  bladders  of 
warm  water  to  be  kept  constantly  applied  to  the  wound  ; 
barley-w^ater  for  drink  and  nourishment,  and  also,  ol. 
ricini.  §ss.  every  two  hours. 

16th.  The  patient  passed  the  fore-part  of  the  night 
pretty  well,  probably  in  consequence  of  two  grains  of  opi- 
um which  he  had  taken  before  the  operation ;  but  he  had 
pain  this  morning  about  the  umbilicus,  recurring  at  short 
intervals.  He  took  four  doses  of  oil  during  the  night, 
but  rejected  them  in  the  morning  by  vomiting.  He  has 
had  no  discharge  from  the  bowels,  but  has  passed  flatus 
repeatedly.  His  stomach  is  irritable,  and  through  the 
dav  he  has  had  singultus.  It  was  concluded  this  morn- 
ing  to  make  an  incision  throughout  the  whole  extent  of 
the  mortified  part.  I  did  it  with  a  scalpel.  Some  liquid 
feces  escaped,  but  the  quantity  was  very  small,  and  I 
began  to  fear  that  there  was  still  some  internal  stricture 
which  prevented  the  evacuation  of  the  bowels.  After  we 


OF  MORTIFIED  BOWEL.  83 

left  him  this  morning,  hquid  feces  flowed  freely,  and  re- 
lieved the  pain  at  the  umbilicus.  This  evening  he  has 
a  preternatural  coolness  of  the  skin  and  clammy  sweats, 
which  make  me  uneasy  about  him ;  he  has,  also,  sin- 
gultus. My  friend  Dr.  Hcwson  saw  him  with  me.  The 
patient  says  he  is  much  relieved,  and  perhaps  his  pre- 
sent state  arises  from  exhaustion.  The  appearance  of 
his  tongue  is  not  bad.  When  the  abdomen  is  pressed, 
it  feels  painful.  Directed  a  very  large  blister  to  the  ab- 
domen; also  porter  and  water  for  drink,  and  if  restless, 
a  dose  of  opium  to  be  given. 

17th.  The  blister  appears  to  have  had  a  very  happy 
effect,  and  the  condition  of  the  patient  is  evidently  im- 
proved. His  pulse  is  better,  his  skin  warmer,  and  the 
discharges  from  the  artificial  anus  very  copious.  Or- 
dered him  to  be  kept  on  a  light,  liquid  diet. 

18th.  The  patient  continues  to  improve.  He  has  had 
copious  discharges  from  the  opening  in  the  bowel,  and 
has  also  had  a  stool  per  anum.  Treatment  continued. 

19th.  The  patient  still  continues  to  improve,  and  says 
he  is  quite  hungry. 

The  patient  continued  to  improve  pretty  regularly ; 
the  mortified  parts  sloughed  very  kindly,  and  healthy 
pus  formed  in  the  divided  parts.  The  discharges  from 
the  bowels  were  free  at  the  artificial  anus ;  the  tension 
of  the  abdomen  subsided  entirely,  and  we  began  to  flat- 
ter ourselves  that  the  danger  was  over.  But  we  were 
disappointed  in  our  hopes.  He  had,  it  will  be  recollected, 
on  the  evening  of  the  1 6th,  a  coolness  of  the  skin,  &c. 
which  soon  went  off".  Several  times  after  this,  I  found 
him  low-spirited  and  languid,  but  he  was  always  relieved 
by  the  tincture  of  assafoetida,  and  Hoflhian's  anodyne, 
given  in  small  and  frequent  doses.  He  had,  also,  chicken 


84  CONSTITUTIONAL  EVIDENCES 

and  mutton  broth,  which  appeared  to  suit  him  very 
wel]. 

On  the  evening  of  the  24th  inst.  the  senior  pupil  of 
the  house  v^^as  alarmed  at  finding  him  in  a  very  low 
state,  and  with  an  irritable  stomach.  His  pulse  had 
fallen,  and  his  skin  was  cold  and  clammy.  Various 
efforts  were  made  to  revive  him,  but  without  effect. 

I  saw  him  on  the  morning  of  the  25th,  sinking 
rapidly.  Every  effort  to  rouse  his  system  failed.  A 
more  than  deathly  coldness  pervaded  the  surface  of  his 
body,  which  was  bedewed  with  sweat.  Respiration  was 
extremely  laborious,  and  appeared,  toward  the  last,  to 
be  performed  entirely  by  the  intercostal  muscles. 
Pressure  on  the  abdomen  gave  no  pain.  The  tongue 
was  moist.  He  died  about  1  o'clock,  P.  M. 

It  is  worthy  of  remark,  that  on  the  afternoon  of  the 
24th  he  was  sensible  of  a  gradual  decline  of  strength 
in  all  the  muscles  of  voluntary  motion,  and  it  appeared 
as  if  a  complete  paralysis  occurred,  previously  to  death, 
in  the  lower  and  upper  extremities. 

Dissection. 

In  the  presence  of  my  friend  Dr.  Hewson,  and  a  num- 
ber of  medical  pupils,  I  examined  the  body  on  the  fol- 
lowing day. 

On  laying  open  the  abdomen,  no  adhesions  were  found 
among  the  intestines  generally,  as  in  peritoneal  inflam- 
mation. The  portion  of  intestine  included  in  the  stric- 
ture was  a  part  of  the  ileum,  about  eight  or  ten  inches 
before  its  termination  in  the  cmmm.  The  strictured 
part  adhered,  very  firmly,  to  the  parts  about  the  ring, 
and  from  the  superior  portion  it  appeared  that  inflam- 
mation had  extended   itself  a   considerable  distance 


OP  MORTIFIED  BOWEL.  85 

along  the  tube ;  but  it  seemed  to  have  been  of  a  low 
grade,  and  had  passed  into  a  state  of  gangrene,  without 
adhesions  being  formed  beyond  the  part  immediately 
involved  in  the  stricture. 


To  illustrate  the  truth  of  the  second  position,  viz.: 
that  the  constitutional  symptoms  of  mortification  may 
exist,  when  the  incarcerated  bowel  is  not  in  a  sphace- 
lated condition,  the  following  case  is  presented. 


CASE  XIII. 


Strangulated  Femoral  Hernia — Deceptive  Symptoms  of 

Gangrene, 

1th  mo.  2d,  1818.  I  was  called  in  the  afternoon,  to 
the  Widows'  Asylum,  by  Dr.  Sargent,  to  see  an  old 
woman  who  had  been  labouring  under  strangulated 
hernia  since  the  evening  of  the  29th  ultimo. 

Dr.  Sargent  was  called  to  her  yesterday,  and  at- 
tempted the  reduction  of  the  parts  by  taxis.  The  patient 
had  been  freely  bled  from  the  arm,  was  placed  in  a 
warm  bath,  had  received  several  purgative  injections, 
and  ice  was  applied  to  the  tumour.  This  morning  she 
was  again  bled,  and  a  tobacco  enema  was  administered, 
which  produced  great  nausea  and  sickness,  but  without 
effect  upon  the  tumour.  She  was  removed  to  the  Hos- 
pital. 

My  friend  Dr.  Hewson  saw  her  with  us.  We  found 
her  entirely  free  from  pain  in  the  tumour  or  abdomen^ 
though  it  had  been  severe  from  the  commencement  of 
the  attack.     The  pulse  was  very  feeble,  the  skin  cool, 


86  CONSTITUTIONAL  EVIDENCES 

and  she  was  affected  with  singultus.  The  whole  aspect 
of  the  case  induced  us  to  suspect  that  the  intestine  was 
mortified.  An  immediate  resort  to  the  operation  was 
advised  as  the  only  alternative ;  and,  after  administer- 
ing a  full  dose  of  laudanum,  I  proceeded  to  perform  it, 
assisted  by  Drs.  Hewson,  Hartshorne,  and  Dorsey,  and 
in  the  presence  of  Dr.  Sargent  and  others. 

The  tumour  lay  below  Poupart's  ligament.  It  was 
of  an  oval  figure,  being  situated  across  the  groin.  I 
made  a  crucial  incision  over  it,  and  dissected  up  the 
corners,  cutting  the  fascia  with  the  silver  director  and 
the  bistoury,  until  the  sac  was  exposed.  This  w  as  care- 
fully opened,  and  freely  divided.  A  small  quantity  of 
bloody  serum  escaped,  hut  it  was  destitute  of  the  cada- 
verous odour.  The  sac  contained  a  small  portion  of  in- 
testine, of  a  very  dark  mahogany  colour,  resembling 
very  much  a  mortified  bowel ;  hut  yet  it  was  concluded 
to  return  it. 

I  next  divided  a  small  stricture  in  the  sac  itself.  In 
passing  the  finger  inward,  in  the  direction  of  the  spine 
of  the  pubis,  to  discover  the  seat  of  the  stricture  at  the 
ring,  I  thought  I  perceived,  rather  indistinctly,  a  slight 
arterial  pulsation.  My  colleagues  were  of  the  same 
opinion.  At  this  moment  the  pulse  at  the  wrist  was 
very  low,  hardly  to  be  perceived,  and  the  artery  was  no 
doubt  influenced  by  the  same  cause. 

I  proceeded  with  great  caution  in  dividing  the  stric- 
ture. By  pushing  my  finger  in  the  direction  of  the  femo- 
ral arch  on  the  pubic  side,  I  was  enabled  to  hitch  up 
the  lower  edge  of  the  tendon  on  my  finger  nail.  The 
blunt-pointed  bistoury  was  introduced  along  side  of  the 
finger  up  to  the  stricture,  and  a  very  small  portion  was 
divided.  This  enabled  me  to  push  forward  the  finger  a 


OF  MORTIFIED  BOWEL.  87 

little  further,  keeping  it  in  advance  of  the  point  of  the 
bistoury,  carefully  feeling  for  the  pulsation,  until  ano- 
ther slight  cut  was  made;  thus  by  enlarging  the  opening 
gradually,  I  was  at  last  enabled  to  pass  my  finger  into 
the  cavity  of  the  abdomen  by  the  side  of  the  strangu- 
lated bowel,  and  thus  reduced  the  protruded  parts  with 
safety. 

The  patient  lost  but  little  blood  during  the  operation, 
though  she  was  exceedingly  exhausted.  We  gave  her 
a  draught  of  wine  and  water,  and  put  her  immediately 
to  bed.  The  pulse  was  very  low,  and  the  skin  cool  and 
clammy.  The  operation  was  completed  between  seven 
and  eight  o'clock  in  the  evening. 

On  visiting  the  patient  at  10  o'clock  at  night,  I  found 
her  better  than  I  had  anticipated.  The  pulse  was  con- 
siderably elevated,  and  the  temperature  of  the  skin  was 
more  natural.  I  directed  barley-water  for  nourishment, 
and  laudanum,  at  short  intervals,  if  restless.  The  bowels 
had  not  been  moved,  but  the  stomach  was  settled. 

3d,  Morning.  The  patient  has  passed  a  good  night; 
is  free  from  pain ;  her  pulse  continues  better ;  her  sto- 
mach retentive ;  tongue  furred ;  abdomen  tumid,  but 
not  tender  to  the  touch.  She  has  had  no  evacuation 
from  the  bowels. — Evening.  In  the  course  of  the  day 
she  had  a  mild  laxative  enema,  which  was  followed  by 
copious  fecal  evacuations.  The  belly  is  less  tumid  and 
without  preternatural  tenderness.  The  tongue  is  furred 
and  moist.  The  patient  has  been  kept  principally  on 
barley-water  since  the  operation.  Her  pulse  is  fuller, 
but  not  active. 

4th.  Morning.  Every  thing  is  going  on  well.  The 
patient  has  passed  an  easy  night ;  her  tongue  is  clean- 
ing rapidly.  She  is  very  desirous  of  something  to  eat» 


88  CONSTITUTIONAL  EVIDENCES 

I  directed  runnet-whey  to  be  added  to  her  diet. — Even- 
ifig.  Still  doing  well.  She  has  some  disposition  to  dis- 
charge from  the  bowels,  without  being  able  to  effect  it. 
Abdomen  tumid,  but  soft.  I  directed  a  mild  injection. 

This  case  went  on  without  any  unpleasant  symp- 
toms ;  the  parts  healed  kindly,  and  the  patient  was  dis- 
charged, cured. 

The  following  case,  which  forcibly  illustrates  the  con- 
dition of  which  we  are  treating,  was  kindly  furnished 
by  my  friend  Dr.  Condie.  I  was  called  to  see  the  pa- 
tient in  consultation  with  Dr.  C,  and  considered,  with 
him,  that  the  case  was  entirely  beyond  the  reach  of 
human  skill.  I  have  rarely  seen  a  recovery  from  a  situ- 
ation so  discouraging. 


CASE  XIV. 

Strangulated  Femoral  Hernia — Apparently  mortal  symp- 
toms— Keduction  by  Stramonium. 

M.  Y.,  a  female  about  fifty  years  of  age,  of  robust 
frame  and  temperate  habits,  had  been  for  some  time 
affected  with  a  reducible  femoral  hernia  of  the  left  side. 
On  the  10th  of  October,  1832,  while  the  patient  was 
engaged  in  some  laborious  occupation,  the  hernia  be- 
came suddenly  strangulated. 

I  saw  her  on  the  morning  of  the  succeeding  day.  The 
hernial  tumour  was  about  the  size  of  a  goose's  egg.  The 
patient  complained  of  acute  pain  extending  from  the 
left  groin  to  the  anterior  part  of  the  abdomen,  which 
latter  was  considerably  swollen,  and  tender  to  the  touch. 


OF  MORTIFIED  BOWEL.  89 

There  was  considerable  febrile  excitement,  with  a  tense, 
quick,  and  frequent  pulse,  and  considerable  nausea. 
The  bowels  had  not  been  evacuated  since,  nor  for  some 
time  preceding  the  strangulation.  As  the  slightest 
pressure  on  the  hernial  tumour  caused  very  great  suf- 
fering to  the  patient,  it  was  impossible  to  attempt,  at  this 
period,  its  reduction  by  taxis.  Eighteen  ounces  of  blood 
were  taken  from  the  arm,  a  purgative  injection  was 
administered,  and  compresses  wet  with  cold  water  di- 
rected to  be  kept  constantly  applied  upon  the  tumour. 

In  the  afternoon  I  found  the  patient  greatly  relieved. 
The  pain  was  less  intense;  the  tenderness  and  tume- 
faction of  the  abdomen  were  diminished ;  and  the  pulse 
was  softer,  more  developed,  and  less  frequent.  So  far 
as  the  obstinacy  and  prejudices  of  the  patient  would 
permit,  an  attempt  was  now  made  to  reduce  the  hernia 
by  taxis  and  the  usual  accessary  means,  but  without  the 
desired  effect.  The  cold  applications  to  the  tumour 
were  directed  to  be  continued,  and  the  injection  to  be 
repeated — the  former  one  having  produced  no  effect  on 
the  bowels. 

During  the  night  the  pain  returned  with  increased 
severity,  and  the  tenderness  of  the  abdomen  was  such 
as  to  render  the  weight  of  the  bed-clothes  intolerable. 
No  discharge  had  taken  place  from  the  bowels.  The 
pulse  was  contracted  and  extremely  frequent ;  the  sur- 
face of  the  body  was  cool  and  dry.  The  slightest  touch 
applied  to  the  hernial  tumour  was  productive  of  great 
distress  to  the  patient.  Ten  ounces  of  blood  were  taken 
from  the  arm;  leeches  to  the  tumour  were  directed,  but 
not  applied ;  the  injection  was  repeated,  and  the  cold 
applications  continued. 

The  more  urgent  symptoms  were  somewhat  abated 

12 


90  CONSTITUTIONAL  EVIDENCES 

on  the  ensuing  day.  The  countenance  of  the  patient, 
however,  evinced  very  great  suffering.  She  remained 
constantly  on  her  back,  with  her  thighs  drawn  up  to- 
wards her  abdomen.  Some  degree  of  dehrium  was 
evinced  in  the  evening.  The  bowels  had  not  been 
opened.  But  httle  was  done  in  the  way  of  treatment. 
The  patient  was  extremely  ignorant  and  prejudiced,  and 
obstinately  opposed  whatever  was  advised.  The  danger 
of  her  case  was  clearly  stated  to  her,  and  the  propriety 
of  a  surgical  operation  was  repeatedly  urged ;  but  "  to 
being  cut  up  alive,"  as  she  expressed  it,  she  declared 
she  never  would  consent,  whatever  might  be  the  re- 
sult. 

On  the  morning  of  the  12th  I  was  sent  for  in  great 
haste.  I  found  the  patient  in  a  state  of  great  prostra- 
tion, with  a  small,  feeble  pulse;  cold,  clammy  skin;  con- 
tracted features ;  and  throwing  up  from  the  stomach, 
at  intervals,  a  dark  green  fluid.  She  complained  of  very 
little  pain,  excepting  when  the  abdomen,  or  hernial  tu- 
mour was  pressed  upon.  The  latter,  which  had  been 
previously  tense  and  elastic,  had  now  a  somewhat 
doughy  feel.  The  vomiting  of  green  fluid  was  suc- 
ceeded, in  the  course  of  the  morning,  by  discharges 
from  the  stomach  of  fecal  matter  in  considerable  quan- 
tities. 

The  patient  now  expressed  a  wish  that  Dr.  Parrish 
might  be  called  in.  This  wish  was  immediately  com- 
plied with,  and  the  doctor  attended  in  the  afternoon, 
accompanied  by  his  son.  The  features  of  the  case  were 
now,  in  our  opinion,  such  as  to  render  all  chance  of  re- 
covery utterly  hopeless ;  and  I  am  convinced  that  any 
medical  man  would  have  concurred  with  us  in  this 
opinion  had  he  examined  the  prostrate  condition  of  the 


OF  MORTIFIED  BOWSL.  91 

patient — the  cold,  clammy  skin — the  feeble,  and  almost 
extinct  pulse — the  sunken  and  contracted  features — 
and  the  fecal  vomitins:. 

It  was  decided  that  from  an  operation  under  such 
circumstances,  but  little  benefit  could  be  expected: — it 
was  agreed,  however,  to  give  the  patient  this  doubtful 
chance  of  relief,  provided  that,  after  a  candid  statement 
to  her,  of  our  views  of  the  case,  she  should  request  it. 
She,  however,  positively  refused  to  submit.  It  was 
agreed,  on  separating,  that  I  should  inform  Dr.  Parrish 
in  the  morning,  of  the  condition  of  the  patient. 

On  calling  the  next  morning  to  see  the  patient,  I 
found  her  still  alive,  and  that  she  had  called  in  a  black 
man,  celebrated  in  the  Neck,  {the  low  country  south  of  the 
city,)  as  "  a  curer  of  ruptures"  both  in  men  and  in  cattle. 
I  remained,  being  somewhat  curious  to  watch  his  pro- 
ceedings. The  hernial  tumour  he  had  covered  with 
a  poultice  of  bruised  herbs — the  leaves,  so  far  as  I  could 
judge  by  the  smell,  of  stramonium — and  he  was  prepar- 
ing an  infusion  of  herbs  to  be  used  as  an  injection. 
This  infusion  was  evidently  of  senna  leaves.  The  in- 
jection he  proposed  to  administer  every  fifteen  minutes, 
by  means  of  a  very  large  and  very  powerful  syringe. 
He  spoke  confidently  of  the  successful  result  of  the 
case. 

I  saw  the  patient  again  on  the  following  morning,  and, 
to  my  utter  astonishment,  found  her  in  a  tolerably  com- 
fortable condition  !  The  hernia  was  reduced ;  all  the 
alarming  symptoms,  under  which  she  had  laboured  on 
the  preceding  day,  were  gone ;  and,  though  extremely 
weak,  she  was  evidently  in  a  fair  way  of  recovery !  I 
learned,  that  after  continuing  the  injections  for  nearly 
two  hours,  there  occurred  a  copious  evacuation  from 


92  •   CONSTITUTIONAL  EVIDENCES  OF  MORTIFIED  BOWEL. 

the  bowels,  of  a  number  of  hard  balls ;  and  that  then, 
suddenly,  the  tumour  had  disappeared  with  a  gurgling 
noise.  These  balls  had  been  preserved  for  my  inspec- 
tion— they  were  formed  of  hard,  dark-coloured  feces,  of 
different  sizes,  from  that  of  a  pea  to  that  of  a  pistol 
ball,  or  even  larger. 

The  patient  continued  daily  to  amend,  and  at  the  ter- 
mination of  ten  days  from  the  reduction  of  the  hernia, 
was  seen  by  me  sweeping  off  her  door! 

Sept.  19th,  1835.  I  saw  her  this  day.  She  enjoys  ex- 
cellent health,  and  so  far  as  I  am  able  to  say  without 
an  actual  examination,  is  radically  cured  of  her  hernia! 


In  forming  an  opinion  of  the  probable  result,  in  a 
case  of  mortified  bowel,  it  becomes  necessary  to  con- 
sider the  astonishing  variety  in  the  human  constitution, 
and  its  ability  to  resist,  or  its  disposition  to  yield  to  the 
operation  of  mechanical  causes,  from  which  it  is  unable 
to  escape.  The  powers  of  this  vis  insita  in  different 
constitutions,  cannot  be  estimated  by  any  known  stand- 
ard. It  is  unmeasurable  and  unknown  until  it  is  sub- 
jected to  trial.  Thus,  in  some  constitutions,  a  very 
small  portion  of  bowel  may  become  strangulated,  and 
in  a  few  hours,  its  death  may  be  effected,  and  all  the 
alarming  symptoms  of  mortification  may  ensue ;  while 
in  others,  mortification  may  exist  for  days,  without  pro- 
ducing the  symptoms  that  usually  mark  its  presence. 


* 


PROOFS  OF  MORTIFICATION  ON  OPENING  THE  SAC.      93 


SECTION   II. 
ON  THE  PROOFS  OP  MORTIFICATION  ON  OPENING  THE  SAC. 

A  careful  examination  of  this  part  of  our  subject  be- 
comes necessary.  The  treatment  to  be  adopted  in  the 
event  of  mortified  bowel,  differs  most  essentially  from 
the  practice  required  for  strangulated  parts  in  a  living 
state.  If,  unhappily  for  the  patient,  the  surgeon  should 
mistake  an  inflamed,  for  a  sphacelated  intestine,  and  in 
an  incautious  moment,  should  lay  it  open  by  a  free  in- 
cision, he  inflicts  a  wound  which  may  prove  fatal. 
Even  if  the  patient  should  escape  with  his  life,  it  is  at 
the  imminent  peril  of  an  artificial  anus,  which,  under 
some  circumstances  would  scarcely  be. preferred  to 
death  itself. 

Persons  who  have  derived  their  information  on  the 
signs  of  mortification  from  systematic  works  on  sur- 
gery, may  consider  them  so  clear  that  they  cannot  be 
mistaken.  They  may  regard  it  as  a  work  of  superero- 
gation to  prove  that  which  is  self-evident ;  but  those 
who  have  encountered  the  difficulties  of  forming  an 
opinion  on  this  point,  at  the  bed-side  of  the  patient, 
will  excuse  me  for  dwelling  for  a  few  moments  on  this 
topic. 

The  colour  of  the  intestine  is  generally  regarded  as 
one  of  the  strongest  evidences  of  mortification.  If  the 
bowel  present  a  dark  and  deep  purple,  approaching  to 
black,  and  if  circulation  be  wanting  in  the  part,  it  may 
be  pronounced  dead.  In  order  to  ascertain  whether 
the  circulation  has  really  ceased,  it  has  been  recom- 


94  PROOFS  OF  MORTIFICATION 

mended  by  some  surgeons,  that  firm  pressure  with  the 
finger  should  be  made  upon  the  suspected  part,  and  if 
the  colour  remains  unchanged,  it  may  be  considered  in 
a  sphacelated  state.  I  freely  admit  that  a  dark  purple 
colour,  and  an  absence  of  circulation,  are  observed  in 
cases  of  real  mortification,  arising  from  a  loss  of  vitality 
in  the  blood-vessels,  and  from  the  consequent  coagula- 
tion of  the  blood.  But  I  fully  believe  that  this  condi- 
tion may  arise  from  the  mechanical  operation  of  the 
stricture,  without  the  integrity  of  the  bowel  being  seri- 
ously injured.  As  a  familiar  illustration  of  this  fact, 
we  may  refer  to  the  simple  experiment  of  tying  a  string 
firmly  round  the  extremity  of  a  finger,  thereby  arrest- 
ing the  circulation  beyond  the  string,  and  producing  a 
dark  blue  or  purple  colour  in  the  part.  The  same  prin- 
ciple will  apply  in  the  case  of  a  stricture  drawn  firmly 
around  a  portion  of  intestine,  whereby  the  circulation 
may  be  suspended  for  many  hours,  without  its  absolute 
death  being  effected. 

If,  in  connection  with  the  dark  colour  of  the  bowel, 
and  an  apparent  absence  of  circulation,  we  should  find 
an  eflfusion  of  lymph  and  adhesions  to  the  surrounding 
parts, — the  result  of  preceding  inflammation, — the 
evidence  of  mortification  would  still  be  insufficient,  be- 
cause this  condition  very  frequently  accompanies  cases 
of  protracted  strangulation  in  which  the  bowel  is  in  a 
living  state. 

I  consider  an  ash-coloured  and  shrivelled  or  collapsed 
state  of  the  intestine^  as  a  much  more  certain  indication 
of  its  death,  than  any  of  the  signs  yet  enumerated. 
Several  cases  will  be  found  in  the  different  sections  of 
this  work,  which  tend  to  prove  this  fact. 

Another  evidence  of  mortification  has  already  been 


ON  OPENING  THE  SAC.  95 

hinted  at,  and  as  far  as  my  experience  extends,  is  con- 
clusive. It  is  the  pecuhar  cadaverous  odour,  emitted 
by  the  contents  of  the  sac  when  opened.  This  odour 
is  well  understood  by  experienced  surgeons.  It  is  my 
invariable  practice,  carefully  to  attend  to  it  in  cases  of 
hernia.  Often  have  my  olfactory  nerves  afforded  deci- 
sive evidence  of  the  melancholy  fact  that  mortification 
had  taken  place,  before  my  eyes  have  had  an  opportu- 
nity of  giving  it  additional  confirmation. 

The  following  highly  interesting  cases  will  confirm 
the  positions  taken  with  regard  to  colour  and  the  ab- 
sence of  circulation. 


CASE  XV. 

Strangulated  Hernia — Intestine  dark,  resemhling  Morti- 

Jication, 

3c?  mo.  3d,  1816.  I  was  called  in  consultation  at  the 
Almshouse  by  Dr.  Hewson,  the  attending  surgeon, 
and  met  him  and  Dr.  Dorsey  at  3  o'clock.  The  patient 
was  a  good-looking  Irishman,  of  middle  age,  who  had 
long  been  subject  to  a  scrotal  hernia,  which  he  was  in 
the  habit  of  reducing. 

The  rupture  had  been  strangulated  for  forty-eight 
hours,  during  which  time  he  had  been  attended  out  of 
the  house  by  Dr.  Emlen,  who  had  bled  him  very  freely, 
and  the  tobacco  enema  had  been  since  administered 
under  Dr.  Emlen's  direction,  without  eflfect.  When  we 
met,  his  pulse  was  upwards  of  100  in  the  minute,  and 
rather  feeble  j  tongue  moist,  and  nearly  natural  in  ap- 


96 


PROOFS  OP  MORTIFICATION 


pearance.  There  was  but  slight  tenderness  or  tension 
of  the  abdomen.  The  scrotum  was  slightly  oedema- 
tous,  and  a  little  discoloured. 

As  the  symptoms  of  strangulation  were  urgent,  it 
was  concluded  to  operate  at  once.  Sixty  drops  of 
laudanum  were  given,  and  Dr.  Hewson  proceeded. 

No  difficulty  was  presented  in  the  course  of  the  ope- 
ration. The  sac  contained  a  large  quantity  of  bloody- 
coloured  fluid,  which  was  not  foetid.  Eight  or  ten  inches 
of  small  intestine  were  found  in  the  sac.  The  principal 
seat  of  stricture  was  at  the  neck  of  the  sac.  The  stric- 
tured  parts  were  divided  by  the  blunt-pointed  bistoury. 
The  intestine  presented  an  unusually  dark  appearance, 
and  some  portions  of  it  were  almost  livid.  It  had  a  very 
suspicious  aspect,  so  much  so,  that  doubts  were  raised 
as  to  the  propriety  of  returning  it.  On  pressing  the 
part  with  the  finger,  no  change  was  produced  in  its 
colour;  which  fact  indicated  the  absence  of  circulation. 

My  opinion  as  to  the  probable  vitality  of  the  bowel 
was  based  upon  the  absence  of  cadaverous  smell  in  the 
contents  of  the  sac,  and  upon  the  want  of  those  adhe- 
sions which  invariably  attend  a  mortified  bowel. 

As  the  case  was  doubtful,  it  was  concluded  to  apply 
bladders  of  warm  water  to  the  surface  of  the  exposed 
intestine,  and  return  in  an  hour  and  a  half,  during  which 
time  we  supposed  that  positive  evidence  would  be  af- 
forded on  the  point ;  and  we  should  be  able  to  decide 
whether  to  put  it  back  or  make  an  incision  through  the 
intestine. 

On  our  return  we  found  a  very  happy  change  had 
taken  place — the  dark  colour  had  nearly  disappeared — 
the  intestine  was  evidently  in  a  state  of  active  inflam- 
mation, and  during  our  absence  a  very  thin,  but  distinct 


ON  OPENING  THE  SAC.  97 

coating  of  coagulable  lymph  had  covered  its  surface. 
Under  these  circumstances  the  bowel  was  returned  into 
the  abdomen.  The  wound  was  dressed  with  strips  of 
sticking  plaster,  and  pledgets  of  lint,  and  the  patient 
placed  in  bed,  with  his  hips  elevated  in  the  usual  man- 
ner ;  after  w  hich  he  took  an  anodyne. 

4th.  The  patient  has  had  a  good  night;  has  passed 
flatus  frequently ;  pulse  somewhat  tense.  Bleeding, 
with  small  doses  of  sulp.  magnes.,  and  the  most  rigid 
antiphlogistic  plan,  w  ere  directed. 

5th.  Has  had  two  free  evacuations  from  his  bowels 
since  yesterday,  and  appeared  better ;  pulse  still  tense. 

We  recommended  the  liberal  use  of  the  lancet,  and 
a  blister  to  the  abdomen,  and  the  patient  ultimately  re- 
covered, under  the  care  of  Dr.  Hewson. 

In  this  case  the  return  of  the  circulation  after  the 
removal  of  the  stricture,  proves  very  satisfactorily  that 
the  dark  colour  was  produced  by  the  force  with  which 
the  bowel  was  enveloped,  impeding  the  circulation  be- 
low the  stricture. 

The  practice  pursued  in  the  above  case — that  of 
covering  the  parts  with  a  bladder  filled  with  warm  w^ater 
in  order  to  imitate  the  natural  temperature — was  derived 
from  my  much  valued  preceptor.  Dr.  Wistar.  It  was 
strongly  recommended  by  him  in  all  cases  requiring 
delay  in  the  progress  of  the  operation  for  hernia. 


13 


98  PROOFS  OF  MORTIFICATION 


CASE  XVI. 

Femoral  Hernia — Dark  colour  of  Bowel — Stercoracious 

Vomiting — Recovery. 

8th  mo.  20th,  1835.  I  was  called  this  day  to  see  the 
wife  of  C.  M.,  a  German  shoemaker  in  Third  street,  in 
consultation  with  Dr.  Moses  B.  Smith. 

The  patient  is  a  woman  of  delicate  form,  forty-two 
years  of  age ;  the  mother  of  five  children.  She  states, 
that  nine  years  ago,  after  the  birth  of  one  of  her  children, 
she  perceived  a  small  tumour  in  her  right  groin.  It  was 
larger  at  some  times  than  at  others,  but  it  has  never 
been  absent.  Dr.  Smith  had  seen  her  on  the  preceding 
day,  and  found  her  labouring  under  marked  symptoms 
of  strangulated  hernia.  An  old  midwife  in  the  neigh- 
bourhood was  in  attendance  before  Dr.  Smith.  The 
attack  commenced  with  a  desire  to  go  to  stool,  followed 
by  a  discharge  from  the  bowels,  accompanied  with  vio- 
lent pain  like  an  attack  of  colic.  An  operation  had  been 
suggested  by  Dr.  Smith,  but  was  at  first  dechned. 

When  I  saw  her,  the  paroxysms  of  pain  were  ago- 
nizing; the  countenance  was  pale  and  dejected;  the 
abdomen  very  tumid  and  tympanitic ;  the  tongue  dry 
and  brown ;  pulse  128,  irritated  rather  than  feeble.  The 
operation  was  proposed  and  acceded  to,  and  Dr.  J. 
Rhea  Barton  was  called  in  consultation.  The  prospect 
of  success  was  greatly  diminished  just  before  the  ope- 
ration, as  she  vomited  a  quantity  of  clearly  marked 
stercoracious  matter.     The  patient  and  her  husband 


ON  OPENING  THE  SAC.  99 

were  candidly  informed  of  the  increased  danger  con- 
nected with  this  circumstance,  but  still  were  desirous 
that  the  operation  should  be  tried.  The  parts  were 
shaved,  and  she  was  placed  on  a  table.  An  anodyne  ene- 
ma had  been  previously  given.  Assisted  by  Drs.  Barton, 
Smith,  and  my  son,  the  operation  was  performed  about 
sixty-eight  hours  after  strangulation.  A  crucial  incision 
was  made  through  the  integuments  in  the  usual  way, 
the  layers  of  fascial  were  divided,  and  the  sac  exposed. 
It  was  found  to  be  extremely  thin;  great  care  was  re- 
quired in  opening  it ;  a  small  portion  was  included  in 
the  forceps,  and  the  incision  was  made  by  cutting  up- 
wards from  the  contents  of  the  sac.  A  small  quantity 
of  fluid  escaped,  which  was  entirely  free  from  cada- 
verous smell ;  the  sac  was  laid  fully  open.  A  portion 
of  omentum,  natural  in  appearance,  first  presented.  On 
turning  aside  the  omentum,  a  knuckle  of  bowel  was 
brought  into  view,  as  dark  in  colour  as  a  ripe  poke- 
berry,  (jjJiytolacca  decandra,)  but  it  was  destitute  of 
cadaverous  smell,andthere  were  no  adhesions  from  in- 
flammation, such  as  are  usually  found  about  mortified 
parts. 

The  stricture  was  divided  in  a  direction  upward  and 
rather  inward,  by  the  blunt  bistoury ;  the  parts  were 
reduced,  and  the  flaps  of  the  wound  approximated  by 
sutures. 

During  the  operation  the  pulse  never  varied,  the  pa- 
tient having  lost  very  little  blood ;  and  when  it  was 
concluded,  she  declared  that  the  pain  suffered  in  the 
operation  was  "  nothing  to  compare"  to  that  produced 
by  the  strangulation.  She  was  removed  from  the  table 
between  3  and  4  o'clock  in  the  afternoon,  and  placed 
in  the  usual  attitude  in  bed.     A  grain  of  opium  was 


100  PROOFS  OF  MORTIFICATION 

given  her,  with  directions  to  repeat  the  dose  in  an  hour 
if  she  was  restless. — Ten  o'clock,  P.  M.  The  patient  is 
much  more  comfortable.  She  has  slept  occasionally, 
and  notwithstanding  the  opium,  she  has  had  four  small 
bilious  stools.  Her  chief  complaint  is  of  griping  pain. 
Her  system  has  reacted ;  her  face  is  flushed;  skin  hot ; 
and  her  pulse  120,  and  febrile.  Directed  her  to  be  kept 
perfectly  quiet ;  another  opium  pill  to  be  given,  if  she 
be  restless ;  and  a  regimen  of  barley-water  and  cold 
water. 

21st,  Morning.  The  patient  has  passed  an  easy  night. 
She  took  one  pill  of  opium  after  the  last  visit.  This 
morning  she  had  a  return  of  stercoracious  vomiting. 
She  has  passed  flatus,  but  her  abdomen  is  extremely 
tympanitic ;  the  urine  is  readily  discharged ;  the  skin 
is  cooler;  pulse  104;  tongue  red,  but  brown  and  dry 
in  the  centre.  Directed  a  table-spoonful  of  castor  oil 
every  two  hours. — Noon.  She  has  taken  one  dose  of 
oil,  and  also  an  injection  of  assafoetida,  after  which  she 
had  one  stool.  She  says  she  "feels  more  natural." 
Her  abdomen  is  rather  less  distended;  her  face  flushed; 
skin  warm,  and  pulse  100,  and  firm. — Evening.  The 
patient  has  retained  three  doses  of  oil,  and  rejected  the 
fourth,  but  without  any  stercoracious  matter.  No  stool; 
skin  hot  and  feverish;  pulse  100,  and  in  other  respects 
much  the  same.  Abdomen  tympanitic ;  the  distended 
arch  of  the  colon,  and  the  convolutions  of  intestine 
being  distinctly  felt  through  the  parietes.  Directed 
occasional  injections. 

22d,  Morning.  Has  greatly  improved  in  every  re- 
spect; passed  a  good  night,  and  has  had  two  large 
bilious  stools.  Pulse  85;  tongue  moist;  abdomen  less 
tumid. — Eveninor.  She   has   had   seven   small    bilious 


ON  OPENING  THE  SAC.  101 

Stools.  Still  improving;  pulse  80;  abdomen  nearly 
natural.  The  patient  relishes  her  gruel,  and  wishes  it 
made  thicker. 

23d,  Morning.  The  patient  was  restless  and  disturbed 
by  dreams  last  night.  She  feels  very  uncomfortable, and 
desires  a  change  of  posture  and  clothing.  She  has  had 
no  stool,  but  passes  flatus  freely.  Pulse  80 ;  tongue 
moist ;  her  abdomen  has  resumed  its  natural  appear- 
ance. Ordered  a  change  of  dress  and  linen. — Evening. 
She  has  had  a  free  discharge  of  indurated  feces  after 
an  enema.  She  takes  her  gruel  with  relish. 

24th.  Morning.  Was  somewhat  feverish  in  the  early 
part  of  last  night ;  pulse  SO ;  no  stool.  I  removed  the 
stitches  from  the  wound.  The  tumour  is  somewhat 
inflamed. — Evening.  There  has  been  one  discharge 
from  the  bowels,  with  scybalse. 

25th.  Has  passed  a  good  night.  Pulse  80.  The 
wound  is  inflamed  and  slightly  painful.  Directed  a 
poultice  to  the  tumour. 

26th.  Pulse  72.  Has  had  one  solid  feculent  discharge 
after  an  enema.  Tumour  still  inflamed.  Ordered  rye 
mush  and  molasses  for  diet. 

27th,  Morning.  The  patient  had  a  restless  night,  some 
fever,  and  unpleasant  dreams.  Her  bowels  have  not 
been  opened  since  yesterday,  although  an  enema  has 
been  given.  The  inflammation  is  extending  around  the 
wound;  there  is  burning  and  soreness  in  the  part;  the 
appetite  is  diminished,  and  the  countenance  is  more 
dejected ;  pulse  78.  Directed  mannaj  opt.  oi.,  sup.  tart, 
potassa?  OSS.,  aqua3  bullicnta)  O.ss.,  a  Avine-glassful  to  be 
taken  every  two  hours. — Evening.  The  medicine  has 
operated  twice.  Pulse  80 ;  tongue  moist.  Feels  much 
better. 


102      PROOFS  OP  MORTIFICATION  ON  OPENING  THE  SAC. 

28th.  Found  her  in  fine  spirits,  sitting  up  in  bed. 
She  has  a  good  appetite.  The  tumour  is  suppurating 
at  a  small  point  at  the  inner  and  lower  part  of  the 
wound.  The  pus  looks  well,  and  is  free  from  any  un- 
pleasant smell.  Directed  a  diet  of  mutton  or  chicken 
broth,  rye  mush  and  molasses,  to  be  continued. 

This  patient  recovered  completely. 


From  the  views  now  presented,  I  would  wish  strongly 
to  impress  the  young  practitioner  with  the  importance 
of  being  on  his  guard  in  all  cases  of  doubt.  Let  not 
colour  of  the  howel^  or  the  apparent  absence  of  circulation 
be  relied  on  as  an  evidence  of  mortification,  unless  con- 
nected with  the  collapsed  state  of  the  intestine^  and  the  ca- 
daverous odour. 


CHAPTER  IV. 


ON  THE  MANAGEMENT  OF  MORTIFIED  BOWEL. 

There  are  two  conditions  of  mortified  bowel  which 
require  separate  consideration.  In  the  first,  the  whole 
calibre  of  intestine  is  in  a  state  of  complete  sphacela- 
tion; while,  in  the  second,  only  mortified  spots  are  de- 
tected on  the  strangulated  part. 

My  experience  in  mortified  bowel  may  not  be  as  ex- 
tensive as  that  of  many  practitioners.  It  has  gone  to 
confirm  the  rule  now  generally  adopted  by  surgeons, 
that  when  the  whole  calibre  of  the  intestine  is  actually 
dead,  the  inflammation  preceding  this  result  has  been 
sufficient  to  fix  the  protuded  parts  to  the  ring  and  its 
immediate  vicinity  by  adhesion;  and  there  is  no  reason 
to  fear  their  being  drawn  into  the  cavity  of  the  abdomen 
by  the  peristaltic  action  of  the  intestines:  hence  no 
necessity  exists  for  inflicting  fresh  violence  on  conti- 
guous parts  by  any  mode  of  practice  designed  to  pre- 
vent such  an  accident. 

In  cases  of  this  description,  after  allowing  sufficient 
time  to  decide  the  question  of  the  actual  death  of  the 
intestine,  it  is  proper  to  open  it  by  incision,  and  thus 
allow  a  free  discharge  of  fecal  matter,  and  then  to 
apply  simple  dressings,  and  leave  the  case  to  nature. 

Several  cases  of  complete  cure,  without  the  occur- 
rence of  fistulous  openings,  arc  related  by  Petit,  in 


104  MANAGEMENT  OF 

which  this  practice  was  adopted.  It  is  remarked  by 
Lawrence,  that  almost  all  the  numerous  instances  of 
recovery  from  mortified  hernia  which  are  recorded  in 
the  annals  of  surgery,  took  place  where  the  surgeon 
was  contented  to  remain  a  quiet  spectator  of  the  pro- 
cess, without  interfering  by  any  artificial  attempts  at 
uniting  the  divided  intestine.  (Lawrence^  Amer.  Edit, 
p.  235.) 

For  the  method  of  proceeding  in  these  cases,  I  refer 
especially  to  the  case  of  the  mulatto  man  at  the  Alms- 
house, related  on  page  81. 

The  proper  method  of  disposing  of  a  strangulated 
intestine,  when  mortified  spots  are  found  upon  it,  has 
given  rise  to  some  discussion  among  surgeons.  A  prac- 
tice formerly  obtained,  of  stitching  a  portion  of  the 
mesentery  to  the  sides  of  the  wound,  to  prevent  the  re- 
turn of  the  diseased  bowel  into  the  abdominal  cavity. 
This  was  founded  on  the  fear  of  the  dead  bowel  being 
drawn  far  away  from  the  external  wound  by  the  peris- 
taltic action  of  the  intestines,  and  thus  acting  as  a 
foreign  substance  in  the  cavity  of  the  peritoneum.  An 
additional  source  of  danger  might  arise  from  the  slough- 
ing of  the  dead  portion  and  the  effusion  of  the  fecal 
contents  of  the  bowels  into  the  abdomen.  But  it  has 
since  been  shown,  by  Dessault  and  others,  that  the  in- 
fllammation  which  always  precedes  the  occurrence  of 
mortified  spots,  is  sufficient  to  restrain  the  bowel  in  the 
immediate  vicinity  of  the  ring,  and  thus  to  insure  the 
passage  of  fecal  contents  through  the  wound. 

It  is  therefore  now  generally  recommended  that,  after 
opening  the  sac  and  dividing  the  stricture,  the  parts 
should  be  gently  returned  into  the  abdominal  cavity, 


MORTIFIED  BOWEL.  105 

leaving  the  result  of  the  case  to  the  operations  of  na- 
ture. 

My  own  experience  as  to  favourable  results  under 
any  mode  of  treatment,  is  very  discouraging.  Hitherto 
it  has  been  my  practice  to  return  the  parts  as  recom- 
mended ;  but  the  fatal  termination  of  the  case  has  so 
generally  followed,  that  I  cannot  speak  with  confidence 
of  any  method.  Cases  are  related,  however,  by  Le- 
dran,  Petit,  Dessault,  Cooper,  and  others,  which  termi- 
nated favourably  under  this  method.  In  some  instances, 
without  the  formation  of  an  artifical  anus,  and  in  others, 
with  this  disgusting  accompaniment. 

Another  plan  has  been  proposed  for  the  treatment  of 
mortified  spots,  which  it  may  be  proper  to  notice.  I 
allude  to  the  applicationof  ligatures  with  a  view  to  hasten 
the  separation  of  the  mortified  parts,  and  to  produce  a 
healthy  union  between  the  surfaces  included  in  the  liga- 
ture. A  case  attended  by  Astley  Cooper,  is  related  by 
Lawrence,*  in  which  this  practice  was  adopted;  the 
parts  were  returned  into  the  abdominal  cavity,  and  the 
patient  recovered.  This  is  high  authority,  and  should 
the  success  of  the  practice  be  confirmed  by  ample  ex- 
perience, I  should  feel  bound  to  adopt  it,  although  its 
propriety  is  at  variance  with  my  present  opinions. 

When  a  small  portion  of  strangulated  intestine  be- 
comes dead,  what  must  be  the  condition  of  parts  in  its 
immediate  vicinity,  which  have  not  yet  completely  yield- 
ed up  their  vitality  ?  They  must  certainly  be  in  an  in- 
flamed condition,  nearly  approaching  to  gangrene.  Un- 
der such  circumstances,  would  the  application  of  a 
ligature  be  most  likely  to  result  in  a  healthy  adhesive 

*  Note  to  Lawrence  on  Ruptures,  p.  226,  Amer.  Edit. 
14 


106  MANAGEMENT  OF 

inflammation  of  the  surrounding  parts,  or  would  it 
not  more  certainly  and  speedily  induce  mortification  ? 
It  seems  to  me,  moreover,  that  the  renewal  of  stricture 
at  such  a  time,  by  a  ligature,  even  on  a  small  portion  of 
bowel,  would  not  be  in  accordance  with  sound  princi- 
ples in  surgery,  when  the  whole  object  of  the  operation 
is  to  remove  strangulation  as  speedily  as  nossible.  Be- 
sides, it  is  well  known  that  the  strangulation  of  one  side, 
or  slip  of  an  intestine  is  sufficient  to  produce  all  the 
symptoms  of  complete  obstruction,  and  has  sometimes 
resulted  in  death.  Several  cases  of  this  kind  are  related 
by  Hey,  in  his  work  on  surgery,  and  one  has  fallen  un- 
der my  notice  at  the  Almshouse.  Hence,  would  there 
not  be  a  risk  of  the  symptoms  of  strangulation  con- 
tinuing, even  after  the  division  of  the  stricture,  and  the 
return  of  the  bowel  ? 


CASE  xvn. 

Ventro  Inguinal  Hernia — Mortified  Spots — Testicle  in- 
volved in  the  Tumour — Death. 

bth  mo.  31st,  1815.  I  was  called  in  haste,  and  after 
night,  to  Germantown,  with  my  friend  Dr.  Hartshorne, 
to  see  J.  D.,  a  man  supposed  to  be  about  forty  years  of 
age.  He  had  been  labouring  under  strangulated  hernia 
from  the  preceding  day,  and  the  usual  means  of  reduc- 
tion had  been  used  without  effect  by  Dr.  Bonsall. 
Among  other  measures  employed  he  had  been  bled; 
but  as  there  was  some  tension  of  his  pulse  still  remain- 
ing, we  concluded  to  bleed  him  again,  while  sitting  erect 


MORTIFIED  BOWEL.  107 

in  bed,  until  he  should  become  fainty,  and  then  to  re- 
peat the  attempt  to  reduce  the  parts  by  taxis.  After 
abstracting  ten  or  twelve  ounces  of  blood,  which  did  not 
occasion  the  patient  to  faint  entirely,  the  taxis  was  tried 
in  vain.  We  then  directed  an  enema,  gave  some  lauda- 
num by  the  mouth,  and  after  w^aiting  about  an  hour, 
proceeded  to  the  operation. 

The  patient  had  never  had  a  descent  of  the  testes  into 
the  scrotum,  and  there  was  hardly  any  appearance  of 
this  receptacle.  The  hernial  tumour  was  large,  and  of 
nearly  an  oval  form;  it  appeared  remarkably  tense, 
and  was  painful  to  the  touch ;  but  there  was  no  tume- 
faction or  tenderness  of  the  abdomen. 

I  made  an  incision  through  the  skin  and  laid  bare  the 
tendon  of  the  external  oblique  muscle.  On  opening  the 
sac,  the  contained  fluid  rushed  out  with  great  force: 
it  had  an  unpleasant  cadaverous  smell.  The  first 
thing  that  presented,  was  a  portion  of  omentum,  of  a 
dark  colour,  and  the  spermatic  cord  lying  in  front  of 
the  sac ;  for  it  appeared  as  if  the  omentum  was  con- 
tained m  one  sac,  and  the  intestine  and  the  testicle  in 
another,  which  occupied  the  superior  part  of  the  tu- 
mour. The  intestine  was  of  a  dark  colour,  interspersed 
with  still  darker  spots,  but  there  was  no  adhesion  to  the 
adjacent  parts. 

The  aperture  from  the  abdomen  did  not  appear  to  me 
to  preserve  that  obliquity  which  is  peculiar  to  the  true 
abdominal  canal.  It  seemed  to  be  nearer  to  the  linea 
alba  than  is  common.  The  stricture  was  firm,  and  must 
have  been  very  severe  in  its  operation.  After  carefully 
dividing  the  stricturing  part  with  the  blunt-pointed  bis- 
toury, the  intestine  and  omentum  were  readily  reduced. 
The  parts  were  dressed  lightly,  and  the  patient  put 


108  MANAGEMENT  OF 

to  bed.  The  testicle  was  permitted  to  remain  in  the 
wound,  for  we  could  not  get  it  into  the  scrotum,  and  it 
was  not  thought  advisable  to  return  it  into  the  abdo- 
men. After  the  reduction  of  the  protruded  parts,  on 
examining  with  my  finger  round  the  ring,  I  thought 
I  could  distinctly  perceive  the  pulsation  of  an  artery 
on  the  outer  part,  toward  the  ileum;  but  as  I  made  the 
incision  directly  upward,  and  with  caution,  it  was 
avoided. 

The  patient  sustained  the  operation  with  remarkable 
fortitude;  but  soon  after  he  was  put  to  bed,  he  was  be- 
dewed with  a  cold  clammy  sweat ;  his  pulse  was  120 
in  the  minute ;  but  still  his  respiration  was  good,  al- 
though he  had  occasional  singultus.  At  first,  I  indulged 
the  hope  that  his  symptoms  resulted  from  transient  ex- 
haustion, and  that  his  system  would  react ;  but  in  this 
I  was  mistaken.  Dr.  Hartshorne  and  myself  left  him  at 
about  2  o'clock,  A.  M.,  and  at  seven  the  same  morning, 
he  died. 

Remarks. 
In  this  case  I  regret  the  bleeding  to  which  we  sub- 
jected the  patient  just  before  the  operation.  Sufficient 
time  had  been  spent  in  eflforts  at  reduction,  and  as  the 
intestine  was  but  partially  mortified,  it  is  possible  that 
an  immediate  resort  to  the  operation  might  have  been 
successful. 

It  has  been  stated,  that  as  a  general  rule,  a  stran- 
gulated bowel  in  a  state  of  mortification,  will  be  found 
so  fixed  by  adhesive  inflammation,  to  the  immediate 
vicinity  of  the  stricture,  that  there  exists  no  necessity 
for  applying  a  ligature  to  the  mesentery  to  prevent 
its  retrocession.    Cases,  however,  may  occur,  that 


MORTIFIED  BOWEL.  109 

may  be  regarded  as  exceptions  to  the  general  rule ;  or 
rather,  that  at  the  time  of  the  operation,  may  lay  out  of 
the  rule,  and  may  subsequently  be  attended  with  diffi- 
culty and  danger.  I  believe  that  the  injury  infficted  on 
an  intestine  by  the  severe  strangulation  or  pinching  of 
so  delicate  a  part,  may  prove  sufficient  ultimately  to 
deprive  it  of  vitality,  even  after  the  original  cause  is 
removed.  All  this  may  occur.  The  intestine,  at  the 
time  of  the  operation,  may  not  present  any  of  the  ap- 
preciable evidences  of  gangrene  which  would  call  for 
specific  treatment.  It  may  be  returned  within  the  cavity 
of  the  abdomen: — it  may  recede  to  some  distance  from 
the  ring — and,  days  afterwards,  the  fairest  prospects  of 
a  recovery  may  be  blasted  by  the  separation  of  a  small 
slough  from  the  side  of  the  bowel.  The  contents  of  the 
intestine  may  pass  into  the  cavity  of  the  peritoneum, 
and  may  actually  be  diffiised  extensively  between  the 
folds  of  the  intestines. 

The  following  case  aflfords  a  striking  illustration  of 
this  fact. 


CASE  XVIII. 

1st  mo.  24th,  1831.  I  operated  to-day,  at  about  one 
o'clock,  P.  M.,  for  strangulated  femoral  hernia,  on  M.C., 
the  wife  of  a  respectable  merchant,  and  the  mother  of 
twelve  children,  several  of  whom  are  yet  young.  She 
had  been  subject  to  a  femoral  hernia  in  her  right  groin 
for  about  a  year,  and  by  my  advice,  had  worn  a  truss. 
The  strangulation  occurred  in  the  act  of  vomiting,  when 
the  truss  was  off. 


110  MANAGEMENT  OF 

I  was  called  to  visit  her  with  my  friend  Dr.  Janney, 
within  twenty-four  hours  after  the  strangulation.  There 
were  some  interesting  particulars  in  the  case.  I  was 
informed,  that  in  the  commencement  of  the  attack  the 
pain  in  the  abdomen  was  very  violent,  and  the  vomit- 
ing severe ;  but  that  these  symptoms  had  subsided 
without  any  treatment  to  explain  it.  She  had  a  large 
feculent  discharge,  which  appeared  to  contain  recent  bile, 
and  which  occurred  without  any  artificial  means,  some 
hours  after  the  operation  of  an  injection  of  decoction 
of  senna. 

Although  1  was  accustomed  to  see  discharges  directly 
after  strangulation,  yet  in  this  case,  I  confess  I  was  in- 
duced to  believe  that  the  stricture  was  removed;  par- 
ticularly as  the  violent  symptoms  which  marked  the 
attack  in  its  commencment  had  greatly  moderated. 

On  the  following  day,  I  discovered  that  the  symp- 
toms had  increased,  though  they  were  not  urgent.  The 
patient  had  no  pain  on  pressing  on  the  abdomen,  or  on 
the  tumour  in  the  groin ;  though  the  symptoms  were 
sufficiently  marked  to  induce  the  suspicion  of  stran- 
gulation. 

On  the  day  preceding  the  operation,  she  had  re- 
peated efforts  at  stool,  with  occasional  slight  discharges 
of  feculent  matter,  and  copious  discharges  of  flatus. 
The  symptoms,  however,  though  not  violent,  continued 
unabated.  She  had  no  pain,  but  an  increasing  languor, 
and  indescribable  distress,  nausea,  and  occasional  vo- 
miting; distressed  countenance;  eructations  and  tym- 
panitic abdomen;  all  of  which  proved  the  existence  of 
strangulation. 

Dr.  J.  Rhea  Barton  was  associated  with  us  in  con- 
sultation; the  usual  remedies  for  reduction  were  faith- 


MORTIFIED  BOWEL.  Ill 

fully  triedj  and  the  operation  was  proposed  on  several 
occasions;  but  the  patient  strongly  objected,  and  did 
not  consent  until  the  24th — being  the  fourth  day  from 
the  commencement  of  the  strangulation. 

I  performed  the  operation,  assisted  by  Drs.  Barton 
and  Janney,  and  my  son.  No  unusual  appearances  were 
presented.  The  sac  contained  a  small  quantity  of  fluid, 
and  a  knuckle  of  bowel  in  an  inflamed  condition, but  not 
gangrenous.  No  cadaverous  odour  could  be  detected. 
The  stricture  was  divided  and  the  parts  returned. 

24th.  Evening.  The  patient  had  two  evacuations; 
after  which,  an  injection  of  lac.  assafcetida  was  admin- 
istered, and  produced  copious  discharges  of  flatus, 
and  the  bowels  were  freely  opened,  to  her  great  relief. 
Her  stomach  is  retentive;  the  eructations  have  nearly 
ceased;  and  the  tympanitis  is  much  diminished.  Her 
pulse  is  intermittent,  and  beats  80  times  in  the  minute. 
A  hop  pillow  was  used  during  the  night. 

25th.  Morning.  The  patient  slept  four  hours  during 
the  night.  An  enema  of  assafoetida  was  administered 
about  midnight.  She  had  two  small  discharges  from 
the  bowels,  and  passed  flatus.  Pulse  about  100.  The 
patient  is  perfectly  free  from  pain;  her  abdomen  soft; 
her  stomach  retentive;  and  she  is  entirely  relieved  from 
nausea  and  eructations.  Her  mouth  and  tongue  are 
dry;  but  the  thirst,  which  was  excessive  during  the 
strangulation,  is  now  much  diminished.  Directed  a 
liquid  farinaceous  diet,  and  a  repetition  of  the  injection 
of  assafoetida,  if  the  bowels  should  be  uneasy. — Even- 
ings 6  o'clock.  She  has  passed  a  comfortable  day.  The 
mouth  and  tongue  are  less  dry;  thirst  diminished.  The 
abdomen  is  not  painful  on  pressure,  though  still  slightly 
tympanitic.  Pulse  100.    Directed  an  injection  of  assa- 


112  MANAGEMENT  OF 

foetida. — 10  o'clock.  After  taking  a  wine-glassful  of  thin 
gruel,  sweetened  with  sugar,  she  complained  of  most 
violent  pain  in  the  belly,  and  in  a  moment  she  became 
extremely  ill  and  very  much  agitated.  Dr.  Janney  and 
myself  were  speedily  called.  We  found  her  pulse  tense 
and  full,  beating  80  strokes  per  minute.  She  was  freely 
bled,  about  twenty  ounces  being  taken,  which  her  pulse 
bore  well;  and  we  directed  an  injection  of  assafoetida 
with  sweet  oil  and  water.  Dr.  Janney  remained  with 
her. 

26th.  Mornings  h  past  9.  The  patient  has  passed  a 
wretched  night.  There  has  been  no  passage  from  the 
bowels,  although  she  has  taken  four  table-spoonfuls  of 
castor  oil.  She  has  had  a  return  of  the  eructations,  but 
no  vomiting.  The  abdomen  is  very  tender  to  the  touch, 
and  somewhat  tympanitic.  The  countenance  dejected. 
Pulse  120,  and  rather  weak.  The  blood  drawn  last 
night  has  no  size  upon  it.  Dr.  Janney  remained  with 
the  patient  until  2  o'clock,  P.  M.  He  applied  a  spice- 
plaster  over  the  stomach,  and  gave  her  an  anodyne 
enema;  but  all  in  vain.     The  patient  died. 

Dissection. — Dr.  Janney  and  my  son  examined  the 
body,  and  afterwards  informed  me  that  there  was 
found  a  perforation  of  an  oval  form,  on  one  side  of  the 
small  intestine,  evidently  formed  by  the  rupture  of  a 
slough.  Through  this  opening  the  contents  of  the 
bowels,  to  the  amount  of  at  least  a  pint  of  fluid  foeces 
had  been  evacuated,  and  diffused  amongst  the  convolu- 
tions of  the  intestines.  The  parts  around  the  slough 
were  but  little  altered  from  their  natural  appearance, 
and  the  size  and  shape  of  the  mortified  portion  induced 
the  belief  that  this  portion  had  been  grasped  by  the 
stricture.    The  intestines  occupied  their  natural  posi- 


MORTIFIED  BOWEL.  113 

tion;  there  were  no  adhesions  of  the  mortified  portion 
to  the  peritoneum,  and  the  bowel  had  receded  about 
two  inches  from  the  ring.  General  peritoneal  inflam- 
mation had  been  caused  by  the  effusion  of  feces,  and 
slight  adhesions  between  the  convolutions  of  the  intes- 
tines  had  taken  place. 


15 


CHAPTER  V. 


ARTIFICIAL  ANUS. 


When  a  strangulated  bowel  becomes  mortified,  if 
death  does  not  ensue,  the  skin  over  the  tumour  sloughs, 
and  the  feces  are  discharged  through  the  opening,  form- 
ing an  artificial  anus. 

This  is  certainly  one  of  the  most  loathsome  condi- 
tions to  which  a  human  being  can  be  subjected.  It  is 
really  deplorable  for  a  person  of  decent  habits  to  pos- 
sess no  power  over  the  alvine  discharges. 

The  artificial  anus  may  be  divided  into  two  species. 
The  mildest  and  most  manageable  form  is  generally 
slow  and  insidious  in  its  approach.  From  the  course 
of  the  symptoms  we  are  led  to  the  conclusion,  that  a 
small  portion  of  the  calibre  of  the  intestine  becomes  par- 
tially strangulated.  The  parts  around  inflame,  and  are 
agglutinated  to  each  other— suppuration  takes  place, 
and  an  opening  is  formed  by  the  ulcerative  process,  be- 
tween the  bowel,  the  sac,  and  the  integuments — and 
an  abscess  appears  externally. 

All  this  may  be  accomplished  with  very  little  consti- 
tutional disturbance,  and  the  first  eyidence  of  a  con- 
nection between  the  abscess  and  the  intestine,  will  be 
exhibited  by  a  discharge  of  feces  and  flatus  at  the 
groin. 


ARTIFICIAL  ANUS.  115 

Patients  of  this  description  may  recover  completely 
under  the  cm'ative  efforts  of  nature.  1  have  seen  several 
instances  of  this  disease,  which  I  will  briefly  narrate. 


CASE  XIX. 

fith  mo,  3d,  1828.  I  was  accustomed  to  attend  a  re- 
spectable old  lady  of  this  city,  of  delicate  constitution, 
and  subject  to  chronic  cough.  While  I  was  in  attend- 
ance, on  a  late  occasion,  she  called  my  attention  to  a 
small  tumour  in  the  groin,  which  excited  no  particular 
anxiety  in  my  mind;  and  I  contented  myself  with  direct- 
ing emollient  applications,  supposing  it  might  be  a  sim- 
ple abscess.  It  advanced  very  gradually  to  suppuration: 
when  this  occurred,  it  was  discovered  that  flatus,  and 
thin  feculent  matter  were  discharged  through  the  open- 
ing. At  the  same  time  the  natural  discharges  through 
the  rectum  were  not  materially  interrupted. 

The  patient  was  very  far  advanced  in  years,  and  died 
in  about  three  months,  from  a  gradual  failure  of  the 
powers  of  nature.  The  discharge  did  not  appear  to 
have  any  agency  in  the  event — during  the  last  month 
of  her  life  it  had  nearly  ceased — and  appeared  to  be 
gradually  diminishing. 

During  the  whole  time  the  functions  of  the  stomach 
and  bowels  were  not  strikingly  impaired. 


116  ARTIFICIAL  ANUS. 


CASE  XX. 

10th  mo.  25th,  1824.  I  accompanied  the  late  Dr. 
Perkin  to  see  S.  S.,  a  young  female  upon  whom  he  was 
attending.  She  had  been  subject  to  a  small  tumour  in  her 
right  groin  from  childhood.  About  four  weeks  previous 
to  my  visit,  while  in  the  act  of  vomiting,  she  had  an  in- 
crease of  the  tumour,  and  an  attack  of  colic.  By  the 
aid  of  injections,  and  a  dose  of  castor  oil,  she  was  re- 
lieved, and  the  next  day  was  pursuing  her  usual  avoca- 
tions. Four  days  after  this  she  partook  of  cold-slaugh, 
(i.e.  chipped  cabbage,)  and  was  again  attacked  with  the 
symptoms  of  colic,  from  which  she  was  relieved  by  the 
same  means. 

At  this  time  she  called  Dr.  Perkin's  attention  to  the 
tumour  in  her  groin — it  was  about  the  size  of  a  bubo, 
and  inflamed.  A  poultice  was  directed,  and  in  a  few 
days  suppuration  took  place,  and  feculent  matter  was 
discharged  through  the  abscess.  Four  days  after  this, 
she  had  a  discharge  from  the  rectum,  and  w^as  greatly 
relieved. 

She  was  kept  upon  a  soft  diet,  and  finally  recovered. 
This  case  is  compiled  from  rough  notes  taken  at  the 
time,  and  is  not  as  detailed  as  I  should  wish.  Dr.  Per- 
kin is  deceased,  and  I  am  not  in  possession  of  a  more 
complete  history. 


ARTIFICIAL  ANUS.  117 


CASE  XXI. 

Umhilical Hernia — SloitgJiingExternally — Natural  Cure. 

In  the  autumn  of  1827,  I  was  called  in  consultation 
with  Drs.  Ellis  and  Lukens,  to  visit  the  wife  of  J.  L.,  a 
worthy  old  citizen  residing  in  Front  street.  The  patient 
was  a  large,  corpulent  woman  about  seventy-seven 
years  of  age.  She  had  lately  received  a  strain  by  falling 
out  of  bed;  and  a  few  hours  afterward,  a  small  tumour, 
about  the  size  of  a  walnut,  w  as  discovered  at  the  um- 
bilicus. 

She  had  been  for  many  years  subject  to  colic,  and 
was  seized,  a  few  days  previous  to  my  visit,  with  an  un- 
usually severe  attack,  which  had  not  yielded  to  the 
usual  remedies.  Dr.  Lukens,  the  family  physician,  was 
called,  and  found  the  bowels  obstinately  constipated, 
with  considerable  pain  in  the  abdomen.  He  prescribed 
the  ordinary  remedies  without  the  desired  effect.  Dr. 
L.  being  absent  from  the  city,  Dr.  Ellis  saw  her.  The 
symptoms  continued  for  several  days,  when  the  atten- 
tion of  her  daughter  was  drawn  to  the  tumour  at  the 
umbilicus — it  was  discharging  a  greenish  offensive  mat- 
ter. Dr.  Lukens  was  sent  for,  and  at  once  discovered 
the  true  character  of  the  case,  and  I  was  requested  to 
see  her  in  consultation.  At  this  time  she  was  dischars- 
ing  large  quantities  of  feculent  matter  from  the  open- 
ing, and  the  evacuations  from  the  anus  were  suspended 
for  several  days.  She  suffered  much  from  excoriations 
over  the  abdomen  caused  by  the  contact  of  feces.  We 
attempted  to  close  the  opening  by  compresses  and 


118  ARTIFICIAL  ANUS. 

bandaging,  but  this  evidently  increased  the  distress  of 
the  patient.  The  sore  was  therefore  left  open,  and  large 
quantities  of  mucilage  of  gum  Arabic  were  applied 
over  the  abdomen,  to  shield  it  from  the  irritating  effects 
of  the  discharges.  The  discharge  continued  for  several 
weeks,  and  finally  ceased  entirely;  the  sore  healed,  and 
the  patient  completely  recovered.  While  the  discharge 
was  declining,  the  patient  took  a  dose  of  sulp.  magnes.  to 
open  the  bowels;  during  the  operation  of  the  medicine 
the  sore  was  re-opened,  and  the  discharge  was  renewed 
as  copiously  as  at  first.  After  this,  the  bowels  were 
moved  by  enemata,  and  the  patient  was  confined  to  a 
farinacious  diet  during  the  whole  course  of  the  attack. 

Remarh, 

It  will  be  observed,  in  the  above  case,  that  a  purga- 
tive caused  serious  mischief  in  the  progress  of  the  cure. 

The  great  principle  of  treatment  in  these  cases  seems 
to  be,  to  avoid  all  kinds  of  cathartics,  and  to  confine 
the  patient  to  a  mild,  soft  diet.  Among  other  articles, 
rye  mush  and  molasses  are  well  adapted  to  such  cases. 


The  danger  attending  an  artificial  anus,  depends 
upon  the  part  of  the  intestine  which  has  been  involved 
in  the  stricture  and  becomes  mortified. 

If  a  portion  of  the  jejunum  be  opened,  the  chyle 
which  was  intended  for  the  nourishment  of  the  system 
may  pass  out  externally:  a  patient  in  this  condition 
becomes  enfeebled  and  emaciated,  and  dies.  A  case 
of  this  description  fell  under  my  observation  at  the 
Pennsylvania  Hospital.  It  is  next  narrated,  as  reported 
in  my  hospital-book  by  my  friend  and  former  pupil  Dr. 
Caspar  Morris,  who  was  then  house-surgeon. 


ARTIFICIAL  ANUS.  119 


CASE  XXII. 

Artificial  Anus — Exhaustion — Death. 

Isaac  Lewis  was  admitted  a  patient  into  the  Penn- 
sylvania Hospital  at  some  time  during  the  sixth  month, 
1824.  He  had  been  afflicted  with  congenital  scrotal 
hernia,  on  the  right  side,  until  some  time  in  the  preced- 
ing summer,  when  he  was  attacked  by  what  was  sup- 
posed to  be  colic,  by  his  physician  in  the  country,  and 
he  was  treated  accordingly.  Sloughing  of  the  integu- 
ments about  the  scrotum  took  place,  and  one  of  the 
testicles  became  involved  in  the  disease.  Such  was  the 
only  account  we  could  obtain  from  the  patient. 

On  his  admission,  a  sinous  opening  was  discovered 
near  the  external  ring.  From  this  orifice  there  was  a 
discharge,  the  nature  of  which  led  to  some  discussion 
among  the  surgeons  of  the  institution,  some  of  whom 
judged  it  to  be  chyle,  and  others  thought  it  was  merely 
purulent  matter.  Considerable  quantities  of  flatus  also 
escaped,  particularly  when  the  patient  rose,  or  when 
pressure  was  made  on  the  abdomen.  The  man  was  in 
an  extremely  weak  and  emaciated  condition,  and  had 
an  obstinate  diarrhoea,  together  with  hectic  fever.  His 
appetite  was  enormous,  and  by  the  use  of  tonics  and 
very  nourishing  diet,  his  health  improved,  though  he 
continued  too  feeble  to  sit  up  or  walk. 

About  the  15th  of  the  Tenth  month,  Dr.  Barton,  assisted 
by  Drs.  Hewson  and  Parrish,  made  an  incision  through 
the  integuments,  and  traced  up  the  sinus  to  the  internal 
ring.    He  was  able  to  pass  a  probe  for  some  distance 


120  ARTIFICIAL  ANUS. 

further,  but  whether  into  the  abdomen  or  into  a  sinus 
between  the  muscles  and  the  peritoneum,  could  not  be 
determined.  After  the  operation  he  was  put  to  bed, 
and  very  soon  discharged  both  from  the  wound  and  the 
rectum,  a  matter  very  closely  resembling  the  shreddy 
evacuations  often  noticed  in  chronic  dysentery.  The 
connection  between  the  sinus  and  the  intestinal  canal 
was  thus  demonstrated  beyond  the  possibility  of  doubt. 
From  this  time  until  the  death  of  the  patient,  which 
occurred  about  ten  days  after,  he  continued  to  have  fecal 
discharges  from  the  wound. 

Dissection.  On  examination,  the  following  appear- 
ances were  presented  in  the  abdomen.  The  whole  of  the 
small  intestines  were  found  agglutinated  by  adhesions 
to  each  other,  to  the  omentum,  and  to  the  abdominal 
parietes.  On  the  right  side  the  adhesion  connected  a 
portion  of  the  jejunum  to  the  peritoneum  just  within 
the  opening  of  the  sinus,  and  a  probe  might  be  passed 
for  a  considerable  distance  into  the  belly,  along  a  sinus 
formed  between  two  barrels  of  intestine,  following  the 
course  of  the  colon.  Towards  the  left  side,  nearly  oppo- 
site the  opening  on  the  right,  was  found  the  cause  of 
the  mischief:  about  three  inches  of  the  intestine  was 
united  by  adhesion  to  the  peritoneum  lining  the  trans- 
verse muscle,  and  at  this  point  there  was  a  communica- 
cation  between  the  cavity  of  the  bowel  and  the  sinus 
already  described. 


The  attempt  was  made  to  explain  these  appearances 
in  the  following  manner.  It  is  probable,  that  after  the 
strangulation  and  during  the  consequent  sloughing  of 
the  bowel,  it  receded  from  the  mouth  of  the  sac,  and 
took  its  position  on  the  left  side  of  the  abdomen,  adher- 


ARTIFICIAL  ANUS.  121 

ing  to  the  surrounding  parts  in  such  a  manner  as  nearly 
to  restore  the  regular  route  of  the  alimentary  canal;  but 
that,  in  the  mean  time,  feces  had  escaped  into  the  cavity 
of  the  peritoneum,  producing  universal  peritonitis.  It 
is  evident  that  the  feces  thus  effused,  had  been  shut  in  by 
adhesions,  and  that,  in  travelling  toward  the  right  abdo- 
minal ring,  which  offered  the  only  outlet,  they  had 
established  the  fistulous  sinus  which  caused  the  death 
of  the  patient. 

When  the  whole  calibre  of  the  intestine  included  in 
the  stricture  becomes  mortified,  a  deformity  of  the  most 
disgusting  character  is  the  result.  The  bowel  being 
doubled  upon  itself,  two  openings  are  formed,  through 
the  upper  of  which,  feces  and  flatus  escape.  The  sides 
of  the  intestine  are  agglutinated  to  each  other  by  ad- 
hesive inflammation  for  some  distance,  presenting  an 
appearance  which  has  been  aptly  compared  to  a  double 
barrelled  gun. 

A  case  of  this  kind  fell  under  the  care  of  Drs.  Wis- 
tar  and  Physick  at  the  Pennsylvania  Hospital,  in  1809, 
in  which  Dr.  Physick  conceived  and  executed  a  most 
admirable  plan  for  the  relief  of  the  patient.  A  full  ac- 
count of  this  interesting  case  was  drawn  up  by  Dr.  B. 
H.  Coates,  and  published  in  the  N.  Amer,  Med.  and 
Surg.  Journ.  vol.  ii.  p.  269.  That  part  of  the  history 
which  relates  to  the  operation  I  have  extracted. 

"  The  next  method  proposed  by  Dr.  Physick,  was  to 
cut  a  lateral  opening  through  the  sides  of  the  intestines 
where  they  were  adherent.  But  not  knowing  the  extent 
of  the  adhesion  inwards,  he  thought  it  necessary  to 
adopt  some  preliminary  measure  for  insuring  its  exist- 
ence to  such  a  depth  AS  might  admit  of  the  contem- 
plated lateral  opening  without  penetrating  the  cavity  of 

16 


122  ARTIFICIAL  ANUS. 

the  peritoneum.  By  introducing  his  finger  into  the  in- 
testine through  one  orifice,  and  his  thumb  through  the 
other,  he  was  enabled  to  satisfy  himself  that  nothing 
intervened  between  them  but  the  sides  of  the  bowel. 
He  was  thus  enabled  without  risk  to  pass  a  needle, 
armed  with  a  ligature,  from  one  portion  of  the  intestine 
into  the  other,  through  the  sides  which  were  in  contact, 
about  an  inch  within  the  orifices,  which  ligature  was 
then  secured  with  a  slip  knot. 

"  This  operation  was  performed  on  the  28th  of  Ja- 
nuary, 1809.  The  ligature  was  merely  drawn  sufficiently 
tight  to  insure  the  contact  of  those  parts  of  the  perito- 
neal tunic  which  were  within  the  noose.  When  drawn 
tighter,  it  produced  so  much  pain  in  the  upper  part  of 
the  abdomen,  of  a  kind  resembling  colic,  that  it  became 
necessary  immediately  to  loosen  it.  The  ligature,  in  this 
situation,  gradually  made  its  way  by  ulceration  through 
the  parts  which  it  embraced,  and  thus  loosened  itself. 
It  was,  at  several  periods,  again  drawn  to  its  original 
tightness. 

"  After  about  three  weeks  had  elapsed,  concluding 
that  the  required  union  between  the  two  folds  of  peri- 
toneum was  insured.  Dr.  Physick  divided  with  a  bis- 
toury all  the  parts  which  now  remained  included  within 
the  noose  of  the  ligature.  No  unfavourable  symptom 
occurred  in  consequence. 

"  On  the  28th  of  February,  the  patient  complained 
of  an  uneasy  sensation  in  the  lower  part  of  the  abdo- 
men; and,  on  the  1st  of  March,  he  extracted  with  his 
own  fingers  some  portions  of  hardened  feces  from  his 
rectum.  On  the  2d  of  March,  two  or  three  evacuations 
were  produced  in  this  manner.  On  the  3d,  an  enema, 
consisting  of  a  solution  of  common  salt  was  directed  to 


ARTIFICIAL  ANUS.  123 

be  given  twice  every  day.  The  first  of  these  occasioned 
a  natural  stool,  about  two  hours  after  its  administra- 
tion. The  same  effect  was  produced  on  the  4th,  5th, 
and  6th;  and  the  discharges  from  the  orifice  in  the 
groin  now  became  inconsiderable.  Adhesive  plasters, 
aided  by  compresses,  were  employed,  not  only  to  pre- 
vent the  discharge  of  feces  from  the  artificial  opening, 
but  with  the  additional  object  of  procuring  the  adhe- 
sion of  its  sides.  This  last  efibrt  was  unsuccessful. 

"  On  the  24th  of  June,  an  attempt  was  made  to  unite 
them  by  the  twisted  suture.  Pins  were  left  in  for  three 
days,  and  adhesion  was,  in  fact,  eflfected;  but  owing  to 
the  induration  of  the  adjacent  parts,  the  wound  again 
opened." 

The  hope  of  an  entire  closure  of  the  orifice  was 
finally  abandoned.  But  the  discharge  of  feces  was  effec- 
tually prevented  by  the  application  of  a  truss,  with  a 
compress  and  large  pad. 

On  the  10th  of  November  the  patient  was  discharged 
from  the  hospital  in  good  health  and  spirits,  and  applied 
himself,  with  very  good  success,  to  acquire  the  profes- 
sion of  an  engraver. 

Had  health  been  restored  in  the  patient,  whose  case 
is  detailed  at  page  81,  (case  xii.)  I  should  have  at- 
tempted to  cure  the  artificial  anus  by  Dr.  Physick's 
method. 


CHAPTER  VI. 


ENTERO-EPIPLOCELE. 


It  not  unfrequently  happens  that  omentum  and  bowel 
are  both  contained  in  a  hernial  sac;  and  when  strangula- 
tion occurs  under  these  circumstances,  the  case  is  ren- 
dered more  complex  and  difficult. 

The  omentum,  in  some  instances,  assumes  such  a 
form  as  to  contain  within  it  a  cavity,  into  which  the 
bowel  descends  and  becomes  strangulated.  If  this  pe- 
culiar relation  of  the  parts  is  not  well  understood  by 
the  surgeon,  he  may  be  greatly  embarrassed  in  the  ope- 
ration, at  a  moment  when  he  should  proceed  with  calm- 
ness and  confidence. 

In  the  preceding  cases  we  have  considered  only  one 
hernial  sac,  as  the  investment  of  strangulated  parts — 
we  have  noticed  the  difficulties  of  opening  the  sac,  from 
an  absence  of  fluid  and  other  causes,  but  still  when  the 
opening  is  eflfected,  the  whole  contents  have  been  fairly 
exposed.  But  what  must  be  the  feelings  of  a  young 
surgeon,  perhaps  in  his  first  operation,  when  he  has 
succeeded  in  detaching  a  hernial  sac  from  its  adhe- 
sions, and  brings  into  view  a  mass  of  omentum,  firmly 
impacted  together  by  strong  adhesive  bands?  What  is 
now  to  be  done?  the  sac  is  opened,  but  no  strangulated 
bowel  can  be  discovered,  although  the  symptoms  une- 
quivocally proclaim  its  existence.     To  suspend  all  fur- 


ENTERO-EPIPLOCELE.  125 

thcr  proceedings,  dress  the  wound,  and  place  the  patient 
in  bed,  is  to  consign  him  to  death,  after  having  sub- 
jected him  to  the  most  painful  part  of  the  operation. 
The  object  must  be  steadily  pursued,  the  operator  must 
recollect  that  a  cavity  is  to  be  found  in  the  centre  of  the 
omental  mass,  which  contains  the  strangulated  bowel : 
he  must  divide  the  omentum,  cutting  as  it  were  through 
the  crown  of  an  arch,  and  he  will  then  discover  that 
there  is  a  sac  within  a  sac,  and  the  intestine  will  be 
brought  into  view. 

The  proper  disposition  of  the  omentum  in  an  entero- 
epiplocele  demands  the  careful  consideration  of  the  sur- 
geon. This  part  may  be  found  very  much  altered  from 
its  original  structure,  from  the  fact  of  its  having  been 
long  excluded  from  the  abdomen;  it  may  be  in  a  state 
of  mortification,  from  the  effects  of  severe  strangula- 
tion; or  it  may  have  recently  descended,  and  be  in  a 
state  of  acute  inflammation. 

The  first  of  these  conditions  I  shall  designate  by  the 
term 

EXPATRIATED  OMENTUM. 

Some  readers  may  smile  at  this  term;  but  perhaps 
they  may  be  convinced  that  it  conveys  a  brief  but  just 
illustration  of  the  condition  of  the  parts. 

It  is  possible  for  a  man  to  absent  himself  for  so  long 
a  period  from  his  native  country,  that  his  early  associ- 
ations may  be  completely  dissevered.  He  may  acquire 
new  views,  he  may  cultivate  other  affections,  and  may 
become  estranged  from  the  land  which  gave  him  birth. 
In  the  course  of  events,  such  an  ahen  from  his  country 
may  return  as  an  enemy,  clothed  in  hostile  array. 


126  ENTEIIO-EPIPLOCELE. 

So  it  is  with  the  omentum;  a  portion  of  this  structure 
may  be  separated  for  so  many  years,  from  the  cavity 
of  the  abdomen,  that  it  may  entirely  lose  its  native  cha- 
racter. Instead  of  a  soft,  yielding  apron  of  fat,  destined 
to  spread  over  the  delicate  bowels,  it  may  become  con- 
verted into  a  solid  mass,  bearing  no  resemblance  to  its 
original  structure,  and  totally  unfitted  for  the  perform- 
ance of  its  appropriate  functions.  It  is  expatriated,  and 
has  become  an  alien  from  its  native  home. 

If  in  this  condition  it  be  forcibly  returned  within  the 
cavity  from  which  it  originally  escaped,  it  may  act  as 
an  extraneous  body,  and  may  prove  an  agent  of  dis- 
cord, danger,  and  death. 

The  treatment  of  omentum  in  this  condition  demands 
serious  consideration,  and  not  unfrequently  surgeons  of 
acknowledged  eminence  have  been  led  into  difficulties. 

The  following  case,  extracted  from  Hey's  Surgery, 
affords  a  striking  evidence  of  the  danger  of  returning  a 
diseased  mass: 

"  February  1st,  1789.  I  was  called  in  the  afternoon 
to  visit  Robert  Walker,  a  poor  man,  aged  thirty-seven, 
who  was  in  great  pain  from  a  strangulated  hernia.  He 
had  been  subject  to  the  hernia  for  many  years.  It  had 
several  times  been  strangulated  for  a  few  hours,  accord- 
ing to  his  account,  and  could  never  be  entirely  replaced 
within  the  abdomen.  The  strangulation  at  this  time 
had  commenced  the  preceding  evening  at  8  o'clock, 
soon  after  which  he  had  a  stool,  but  afterwards  had  no 
evacuation.  He  vomited  sometimes,  and  had  a  little 
hiccough.  His  belly  was  somewhat  tense,  but  not  much 
inflated.  His  tongue  rather  white.  His  pulse  soft  and 
calm  at  sixty-four.  The  lower  part  of  the  tumour  in 
the  scrotum  was  soft;  the  upper  part  was  hard.    The 


ENTERO-EPIFLOCELE.  127 

scrotum  was  so  thin,  that  I  could  feel  the  omentum 
within  the  hernial  sac. 

"  I  ordered  a  clyster,  made  with  two  drachms  of  to- 
bacco boiled  in  a  pint  of  water  for  ten  minutes,  to  be 
injected;  and  cloths  dipped  in  cold  water  to  be  assidu- 
ously applied.  I  did  not  bleed  him,  as  his  pulse  was  so 
soft  and  calm.  The  clyster  had  a  powerful  effect,  pro- 
ducing great  sickness  and  vomiting,  with  a  cold  sweat, 
during  which  the  pulse  sunk  to  fifty-six.  I  attempted 
during  this  languor  to  reduce  the  hernia,  but  in  vain; 
not  the  least  motion  was  produced  by  my  attempts. 

"  I  most  strongly  recommended  the  operation,  and 
advised  the  poor  man  to  go  into  the  infirmary,  as  the 
accommodations  of  his  house  were  very  bad.  My  ad- 
vice did  not  prevail,  so  I  gave  him  in  the  evening  fifty 
drops  of  tinct.  opii.,  which  entirely  removed  his  pain 
and  vomiting.  The  next  day  the  poor  man  consented 
to  go  into  the  infirmary,  but  not  till  towards  evening. 
The  pain  had  now  returned,  the  abdomen  was  more 
inflated  and  tense,  and  the  tumour  was  larger.  The 
operation  was  immediately  performed. 

"  Not  the  least  quantity  of  fluid  issued  out  when  the 
hernial  sac  was  opened.  A  large  portion  of  omentum, 
and  a  smaller  of  intestine,  were  the  contents.  The  former 
appeared  to  have  laid  a  considerable  time  in  the  her- 
nial sac;  for  it  not  only  adhered  to  the  sac  in  many 
places,  but  also  had  formed  in  it  several  small  pouches, 
in  which  it  lay  depressed  beyond  the  level  of  the  sac. 
The  intestine  was  dark-coloured,  but  had  contracted  no 
adhesion.  The  stricture  was  not  formed  by  the  abdo- 
minal ring,  but  entirely  by  the  neck  of  the  hernial  sac, 
into  which  I  could  not  introduce  the  least  portion  of 
my  finger. 


128  ENTERO-EPIPLOCELE. 

"  I  was  obliged  to  divide  the  ring  pretty  high,  that  I 
might  with  safety  divide  the  neck  of  the  sac;  and  this 
last  division  was  effected  by  cutting  along  the  groove 
of  a  director,  till  I  had  made  a  sufficient  aperture  for 
the  introduction  of  my  finger.  As  the  omentum  adhered 
to  the  sac  by  little  cords,  which  might  easily  be  divided, 
I  separated  it  from  the  sac,  and  reduced  it  immediately 
after  the  intestine.  This  was  easily  reduced,  but  the 
reduction  of  the  omentum  gave  some  trouble.  The 
omentum  did  not  feel  brittle,  nor  appear  to  be  in  a  gan- 
grenous state.  When  the  contents  of  the  hernia  were 
reduced,  some  serous  fluid  issued  out  of  the  abdomen. 
A  purging  clyster  was  ordered  to  be  injected;  and-  he 
was  directed  to  take  half  an  ounce  of  castor  oil  every 
two  hours,  till  a  free  evacuation  should  be  produced. 

"  February  3d.  I  found  him  in  a  good  state  at  noon; 
the  clysters  had  produced  a  stool,  and  after  the  second 
dose  of  castor  oil  he  had  three  evacuations.  His  pulse 
was  at  eighty-six. 

"  Notwithstanding  these  favourable  appearances,  the 
symptoms  of  inflammation,  such  as  vomiting,  soreness 
of  the  abdomen,  with  considerable  pain,  returned  in  the 
evening.  Eight  ounces  of  blood  were  taken  from  his 
arm;  a  clyster  was  injected;  the  ol.  ricini  was  repeated; 
and  a  large  blister  was  applied  to  the  abdomen.  These 
means  afforded  no  relief,  and  the  poor  man  died  at 
seven  in  the  morning. 

"  In  the  evening  I  examined  the  contents  of  the  abdo- 
men. The  intestines  appeared  in  many  places  inflamed, 
and  adhered  to  each  other  universally.  That  part  which 
had  been  strangulated  was  of  a  darker  colour.  The 
omentum  did  not  cover  the  anterior  surface  of  the  in- 
testines as  usual,  but  passed  down  on  the  left  side  of 


ENTERO-EPIPLOCELE.  120 

the  abdomen,  collected  together  like  a  thick  rope.  The 
strangulated  portion  had  now  become  very  brittle,  and 
was  dark  coloured  at  its  inferior  part.  Bloody  serum 
was  contained  within  the  abdomen." 

Here  is  an  instance  of  death  resultincr  from  the 
practice  of  returning  a  portion  of  expatriated  omentum 
into  the  abdominal  cavity.  A  case  somewhat  similar, 
though  not  resulting  in  death,  occurred  several  years 
ago  in  the  Pennsylvania  Hospital,  under  the  care  of  Dr. 
J.  Rhea  Barton. 

A  patient  was  admitted  with  strangulated  entero- 
epiplocele,  and  was  operated  upon  by  Dr.  Barton.  A 
large  mass  of  hardened  omentum  was  found  in  the  sac, 
which  was  returned  with  the  bowel  into  the  abdomen. 
A  train  of  the  most  alarming  symptoms  speedily  en- 
sued, causing  great  solicitude  for  the  life  of  the  patient. 
Finally,  abscess  formed  in  the  groin,  at  the  wound, 
through  which  several  large  masses  of  dead  omentum 
were  discharged.  Dr.  Barton  thought  that  the  quantity 
of  solid  matter  discharged,  was  almost  equal  to  three- 
fourths  of  the  whole  omentum  in  its  natural  state.  The 
discharge  was  kept  up  for  several  weeks,  during  which 
time  the  strength  of  the  patient  was  supported  by  a 
generous  diet,  and  he  was  ultimately  discharged  cured. 

A  practice  was  reconmiended  by  some  of  the  old 
writers,  which  is  still  more  dangerous  than  the  preced- 
ing. It  consisted  in  tying  a  ligature  firmly  around  the 
root  of  the  hardened  mass,  removing  the  portion  below 
the  ligature,  and  returning  the  part  with  the  ligature 
attached,  and  its  end  retained  on  the  outside.  A  num- 
ber of  cases  are  on  record,  where  this  practice  has 
actually  proved  fatal,  even  in  the  hands  of  eminent 


surgeons. 


17 


130  ENTERO-EPIPLOCELE. 

In  the  surgical  works  of  Percival  Pott,  a  case  is 
very  candidly  stated,  in  which  this  practice  caused  the 
death  of  an  individual. 

The  patient  had  long  been  affected  with  a  bubono- 
cele, which  was  inconvenient  from  its  bulk  alone — he 
applied  to  Pott  to  remove  it,  which  he  accordingly  did. 
A  ligature  was  applied  around  the  root  of  the  diseased 
mass,  and  the  omentum  below  removed.  The  patient 
at  the  time  of  the  operation  was  in  perfect  health;  but 
a  train  of  the  most  violent  symptoms  ensued,  which 
resulted  in  his  death. 

So  many  proofs  of  the  dangerous  effects  of  this  plan 
of  treatment  have  been  adduced,  that  I  believe  it  is  now 
generally  abandoned. 

To  counteract  the  dangers  arising  from  this  plan,  it 
was  recommended  by  Pott  to  excise  the  diseased 
omentum,  and  return  the  sound  parts  into  the  abdomen 
without  the  application  of  a  ligature  at  its  root.  He 
believed  that  the  risks  of  hemorrhage  by  such  a  course, 
were  much  less  than  surgeons  generally  supposed. 

I  have  never  seen  this  practice  adopted,  and  there- 
fore cannot  speak  of  it  from  experience;  but  I  should 
consider  that  the  division  of  the  large  blood-vessels, 
near  the  root  of  the  omentum,  must  necessarily  give 
rise  to  bleeding,  which  would  prove  dangerous  to  the 
patient.  At  the  same  time  it  must  be  admitted,  on  the 
authority  of  Pott,  that  the  practice  has  in  some  cases 
been  safely  pursued.  Two  cases  are  reported  by  Hey, 
of  Leeds,  in  which  he  pursued  this  practice,  on  the  re- 
commendation of  Pott,  and  dangerous  hemorrhage 
ensued.  An  abstract  of  one  of  these  I  shall  detail  in 
this  place,  in  the  absence  of  any  experience  of  my  own. 
It  is  taken  from  Hey's  Surgery,  p.  188,  second  edition. 


ENTERO-EPIPLOCELE.  131 

"  Case. — The  hernial  sac  contained  a  good  deal  of 
serous  fluid,  besides  a  pretty  large  portion  of  intestine 
enveloped  and  completely  covered  by  omentum.  The 
neck  of  the  hernial  sac,  below  the  abdominal  ring, 
formed  so  considerable  a  stricture,  that  I  could  not  in- 
troduce the  tip  of  my  finger  to  guide  the  curved  bis- 
toury. It  even  required  some  force  to  introduce  a  di- 
rector suitable  to  this  occasion.  After  dividing  the  neck 
of  the  hernial  sac,  I  could  easily  introduce  my  finger 
within  the  abdominal  ring,  which  I  also  divided  suffi- 
ciently to  permit  the  reduction  of  the  intestine. 

"  The  omentum  was  become  gangrenous;  and  in  one 
part  adhered  pretty  strongly  to  the  intestine.  That 
part  of  the  intestine  which  had  been  enclosed  in  the 
stricture  made  by  the  neck  of  the  hernial  sac,  appeared 
as  if  it  had  been  tied  round  by  a  string.  The  colour 
was  so  much  altered  by  this  impression,  that  we  were 
under  considerable  apprehension  of  a  separation  taking 
place  at  this  part.  I  endeavoured  to  reduce  the  intes- 
tine with  all  possible  gentleness,  after  I  had  separated 
it  from  the  omentum;  yet,  notwithstanding  all  the  cau- 
tion I  could  use,  I  was  much  afraid  that  the  operation 
would  not  preserve  the  life  of  my  patient,  even  if  no 
injury  should  arise  from  the  morbid  state  of  the  omen- 
tum. 

"  I  had  always  been  afraid  of  large  wounds  of  the 
omentum;  but  as  the  excision  of  a  gangrened  portion, 
by  cutting  through  the  adjacent  sound  part,  stood  so 
strongly  recommended  by  Mr.  Pott,  of  whose  judgment 
I  had  a  very  high  opinion,  I  determined  to  follow  his 
example  in  this  instance.  I  cut  off",  therefore,  all  that  had 
a  morbid  appearance;  and  the  remainder,  as  soon  as  I 


132  ENTERO-EPIPLOCELR. 

had  ceased  to  hold  it,  retired  spontaneously  into  the 
abdomen. 

"  A  hemorrhage  immediately  ensued,  which  from  the 
distinct  colours  of  different  parts  of  the  stream,  evidently 
consisted  both  of  arterial  and  venous  blood.  The  dis- 
charge of  blood  diminished  so  much  in  a  short  time, 
that  I  ventured  to  unite  the  divided  integuments  through 
the  whole  extent  of  the  wound,  by  the  interrupted  suture. 
I  ordered  a  purging  clyster  to  be  injected,  and  half  an 
ounce  of  ol.  ricini  to  be  given  every  three  hours,  till  a 
free  evacuation  should  be  produced. 

"  I  visited  the  patient  about  two  hours  after  the  ope- 
ration and  found  him  asleep. 

"At  ten  in  the  evening  I  was  called  to  him,  on  account 
of  a  violent  hemorrhage,  which  the  nurse  had  just  dis- 
covered. The  blood  had  flowed  through  his  bed  upon 
the  floor.  I  immediately  cut  out  the  ligatures  which 
were  in  the  upper  part  of  the  wound,  both  to  give  a  free 
issue  to  the  blood,  and  also  to  enable  me  to  know  the 
true  state  of  the  hemorrhage.  The  blood  which  now 
issued  out  appeared  to  be  venous.  It  flowed  irregularly, 
sometimes  ceasing  for  ten  or  twelve  minutes.  I  applied 
cloths  dipped  in  cold  water  to  the  abdomen  and  scro- 
tum, and  kept  dabbing  the  wound  with  a  cold  wet 
spunge.  His  pulse  was  weak,  and  at  a  hundred  and 
eight.  His  countenance  more  pale;  the  belly  less  tense; 
he  had  one  stool.  I  left  him  at  half  past  eleven,  as  the 
hemorrhage  had  then  abated,  desiring  the  house  apo- 
.thecary  and  my  senior  pupil  who  remained  with  him, 
to  continue  the  application  of  the  cold  cloths  till  the 
hemorrhage  should  cease,  and  to  give  the  ol.  ricini 
every  three  hours. 


ENTERO-EPIPLOCELE.  133 

"  27th.  The  hemorrhage  ceased  at  half  past  one  in  the 


morning." 


The  patient  finally  recovered;  and  the  experienced 
writer  makes  the  following  remarks: 

"  This  case  clearly  shows,  that  large  wounds  of  the 
omentum  are  attended  with  danger,  if  the  bleeding  ves- 
sels  are  not  tied.  As  the  termination  was  favourable,  I 
am  not  sorry  that  the  operation  was  performed,  as  Mr. 
Pott  and  Monsieur  Caque  have  advised;  but  I  shall 
never  again  cut  off  any  large  portion  of  omentum,  with- 
out applying  a  ligature  to  every  bleeding  vessel,  whe- 
ther artery  or  vein,  before  I  permit  the  remainder  of 
the  omentum  to  retire  into  the  abdomen." 

A  third  plan  of  treatment  consists  in  the  excision  of 
the  diseased  mass,  securing  the  divided  blood-vessels 
separately,  by  fine  ligatures,  and  returning  the  parts, 
allowing  the  ends  of  the  ligatures  to  remain  outside  of 
the  w^ound. 

This  practice  is,  I  believe,  very  generally  recom- 
mended by  surgical  writers  at  the  present  day;  but  I 
must  confess  it  is  utterly  at  variance  with  my  views  of 
sound  surgical  principles.  By  such  a  course  the  imper- 
fection of  one  of  the  most  important  cavities  in  the 
body  is  maintained  for  many  days,  and  the  patient  is 
also  subjected  to  the  additional  risk  of  peritoneal  in- 
flammation, arising  from  the  presence  of  extraneous 
bodies. 

In  pursuing  such  a  plan,  do  we  not  carry  out  the  same 
principles  which  govern  us  in  the  operation  for  the  ra- 
dical cure  of  hydrocele?  If  the  introduction  of  a  seton 
or  ligature  in  the  cavity  of  the  tunica  vaginahs  testes 
will  cause  acute  inflammation,  the  effusion  of  lymph, 
and  adhesion  between  the  opposing  surfaces  of  the 


134  ENTERO-EPIPLOCELE. 

peritoneum,  the  same  result  may  be  anticipated  in  an- 
other cavity  hned  by  the  same  membrane. 

If  the  ntihty  of  this  practice  were  confirmed  by  am- 
ple experience,  I  should  be  disposed  to  adopt  it,  although 
in  opposition  to  my  present  views.  I  have  searched  in 
vain  for  its  confirmation,  by  detailed  accounts  of  cases 
in  which  such  a  course  has  been  sucessfully  pursued. 

A  case  is  published  by  Everard  Home,  in  the  Trans- 
actions of  a  Society  for  the  Improvement  of  Medical 
and  Chirurgical  Knowledge,  vol.  ii.  p.  99,  in  which  he 
pursued  this  practice;  and  its  result  is  certainly  not  cal- 
culated to  make  a  very  strong  impression  in  its  fa- 
vour. The  patient  was  afflicted  with  strangulated  fe- 
moral hernia;  and  the  writer,  after  describing  her  sym- 
toms,  &c.  thus  proceeds : 

"  When  I  laid  open  the  hernial  sac  in  the  usual  man- 
ner, nothing  except  omentum  was  brought  to  view;  but 
when  this  was  spread  out,  and  turned  up  towards  the 
abdomen,  a  small  tumour,  formed  by  the  doubling  of 
the  intestine,  was  discovered  at  the  bottom  of  the  sac, 
which  was  so  much  pressed  upon  by  Poupart's  ligament, 
as  not  to  admit  the  end  of  a  probe  to  pass  between 
them.  The  gut  was  very  much  inflamed,  its  surface 
was  perfectly  smooth,  and  uniformly  of  a  dark  red  co- 
lour; but  as  mortification  had  not  taken  place,  it  was 
thought  to  be  capable  of  recovery,  and  was,  therefore, 
as  soon  as  the  ligament  was  divided,  returned  into  the 
belly.  The  portion  of  omentum  adhered  to  the  orifice 
of  the  hernial  sac,  and  was  found  upon  trial  too  large  to 
pass  through  the  orifice  which  led  to  the  abdomen;  it 
was,  therefore,  from  necessity,  removed;  this  was  done 
by  dividing  it  in  its  expanded  state,  near  the  orifice  of 
the  sac,  with  a  pair  of  scissors;  two  arteries  on  the  cut 


E^fTERO-EPIPLOCELE.  135 

edge  bled  so  violently  as  to  require  being  secured  by 
ligatures,  the  ends  of  which  were  brought  out  at  the 
external  wound  and  the  whole  was  superficially  dressed. 

"  As  the  portion  of  gut  was  very  much  inflamed, 
twenty  drops  of  tincture  of  opium  were  given  imme- 
diately, to  lessen  the  irritation  produced  by  the  inflam- 
mation, and  repeated  at  four  in  the  morning. 

"  January  2d.  The  retching  was  entirely  stopped, 
and  the  pain  in  the  belly  much  abated.  A  glyster  of 
warm  water  was  injected,  and  fifteen  drops  of  tincture 
of  opium  given  in  a  draught,  both  of  which  were  re- 
peated at  night.  The  glysters  were  only  retained  about 
an  hour. 

"  January  3d.  She  was  totally  easy,  but  languid;  the 
glyster  of  warm  water  was  repeated:  at  ten  in  the  even- 
ing she  had  a  pain  in  the  lower  belly,  for  which  she 
took  twenty  drops  of  tincture  of  opium:  the  same  quan- 
tity of  opium,  in  consequence  of  a  continuance  of  the 
pain,  was  repeated  at  one  in  the  morning. 

"  January  4th.  The  pain  continued  with  a  constant 
desire  to  make  water;  the  belly  was  fomented,  after 
which  she  made  water  freely,  and  this  relieved  the  pain 
in  the  belly.  At  2  o'clock  she  took  an  ounce  of  a  mix- 
ture containing  svj.  of  infusion  of  senna,  3vj.  of  tinc- 
ture of  senna,  and  3iii.  of  kali  tartarisatum,  and  in  an 
hour  had  a  motion;  her  pulse  was  soft,  and  beat  a  hun- 
dred times  in  a  minute;  her  thirst  continued,  but  was 
relieved  by  sucking  oranges.  She  took  some  panada, 
sago,  and  her  usual  opiate  at  night. 

"  January  5th.  Had  a  confusion  in  the  head,  with 
disturbed  dreams;  these  were  considered  as  effects  of 
opium,  which  was  therefore  left  off*.  The  wound  had  a 
favourable  appearance. 


136  ENTERO-EPIPLOCELE. 

"  January  7th.  The  hgatures  came  away,  and  the 
wound  was  going  on  kindly, 

"  January  9th.  She  became  restless,  feverish,  lan- 
guid, and  had  no  appetite  for  food;  all  these  symptoms 
increased  on  the  10th,  and  on  the  11th  at  night,  she 
died,  exactly  ten  days  after  the  operation. 

"  On  inspecting  the  body  after  death,  the  strangulated 
portion  of  intestine,  extending  to  two  inches  and  a  half 
of  the  ileum  in  length,  was  found  to  have  exactly  the 
same  appearance  as  it  had  when  exposed  during  the  ope- 
ration. Its  internal  membrane  was  extremely  vascular, 
and  had  an  inflammatory  exudation  of  coagulating 
lymph  adhering  to  different  parts  of  its  surface.  There 
was  no  appearance  of  inflammation  on  the  omentum. 
So  large  a  portion  of  it  had  been  removed  during  the 
operation,  that  only  an  inch  of  its  anterior  part  re- 
mained attached  to  the  transverse  arch  of  the  colon. 
In  several  parts  of  the  abdomen  there  were  slight  adhe- 
sions between  diflferent  convolutions  of  the  intestines." 

In  this  case  the  symptoms  were,  from  the  beginning 
of  the  attack,  those  of  an  inflamed  intestine;  the  ope- 
ration arrested  the  progress  of  the  inflammation,  and 
prevented  mortification  from  taking  place;  but  the  in- 
flammation had  proceeded  too  far  to  admit  of  resolu- 
tion. 

The  death  of  the  patient  is  referred  to  enteritis,  in- 
duced previously  to  the  operation.  But  whether  the 
hgatures,  by  acting  as  extraneous  bodies  in  the  abdo- 
minal cavity  may  not  have  an  agency  in  increasing  the 
inflammation,  and  producing  those  adhesions  between 
diflferent  convolutions  of  the  intestines,  is  undeter- 
mined. 

In  the  valuable  work  of  Astley  Cooper  on  the  Ana- 


ENTERO-EPIPLOCELE.  137 

tomy  and  Surgical  Treatment  of  Inguinal  and  Congeni- 
tal Hernia,  I  find  the  following  remarks  in  reference 
to  the  treatment  of  diseased  masses  of  omentum. 

"  When  the  intestine  has  been  returned,  the  omen- 
tum is  to  be  examined  with  attention,  and  if  it  is  in  a 
healthy  state,  or  not  of  considerable  bulk,  it  should  be 
returned  into  the  cavity  of  the  abdomen  by  as  slight  a 
pressure  as  possible.  But  if  it  is  very  bulky,  a  part  of  it 
should  be  removed,  which  may  be  done  with  the  knife 
with  great  freedom,  and  if  properly  managed,  without 
any  danger.  I  have  myself  removed  it,  in  several  in- 
stances, without  the  patient  seeming  to  suffer  any  sub- 
sequent inconvenience. 

"  The  surgeon  raising  the  omentum,  whilst  an  assist- 
ant grasps  it  higher  up,  to  prevent  its  return  into  the 
abdomen,  cuts  it  off  near  the  mouth  of  the  sac.  Some 
small  arteries  always  bleed,  which  are  to  be  secured 
by  a  fine  ligature;  and  when  the  hemorrhage  is  stopped, 
the  omentum  is  to  be  returned  into  the  abdomen,  with 
its  divided  surface  applied  to  the ,  mouth  of  the  sac, 
from  which  the  ligatures  are  suspended,  and  it  thus 
forms  a  plug  which  shuts  up  its  cavity."  P.  32. 

The  recommendation  of  a  surgeon  so  justly  distin- 
guished as  the  writer  of  the  above  quotation,  is  entitled 
to  high  respect,  and  it  is  with  diffidence  that  I  offer  a 
few  plain  objections  to  the  practice  here  proposed. 

The  omentum  to  be  treated,  so  far  as  I  understand 
the  case,  is  not  in  a  state  of  mortification,  neither  is  it 
fixed  by  adhesions  within  the  sac.  The  directions  given 
for  its  excision  lead  us  to  infer  that  it  lies  loosely  in  the 
sac,  and  that  it  must  be  secured  by  an  assistant  to  pre- 
vent the  danger  of  its  retrocession  into  the  abdominal 
cavity  before  the  ligatures  are  applied  to  the  bleeding 

18 


138  ENTERO-EPIPLOCELE. 

vessels.  After  this,  the  remaining  omentum  "  is  to  be 
returned  into  the  abdomen  with  its  divided  surface  ap- 
pHed  to  the  mouth  of  the  sac,  from  which  the  hgatures 
are  suspended."  Here  let  me  inquire,  what  security  has 
the  surgeon,  that  the  omentum  thus  returned,  will  not 
recede  from  the  mouth  of  the  sac,  and  carry  the  liga- 
tures within  the  abdominal  cavity.  When  we  consider 
the  powerful  peristaltic  action,  in  the  arch  of  the  colon, 
to  which  the  omentum  is  attached,  in  every  act  of  de- 
jection, I  can  discover  no  rational  ground  of  hope  for 
its  being  retained  precisely  at  the  mouth  of  the  sac. 
If  it  be  deemed  expedient  by  many  surgeons,  to  stitch 
the  mesentery  to  the  side  of  the  wound  in  case  of  a 
mortified  spot  on  the  bowel,  to  prevent  its  retrocession, 
it  seems  to  me  very  hazardous  to  trust  a  portion  of 
omentum,  which  is  not  fixed  by  adhesion  to  the  sac, 
and  which  is  subjected  to  all  the  chances  of  displace- 
ment from  the  motions  of  the  intestine. 

If  the  recommendation  of  Cooper  had  alluded  simply 
to  a  portion  of  irreducible  omentum,  which  had  been 
firmly  fixed  by  old  adhesions  to  the  hernial  sac,  the 
safety  of  the  practice  could  be  more  readily  admitted. 
My  own  limited  experience  supplies  a  case  of  this  kind, 
in  which  a  portion  of  omentum  in  this  condition  was 
excised,  a  ligature  was  applied,  and  the  patient  reco- 
vered. 


ENTERO-EPIPLOCELE.  139 


CASE  XXIII. 

Entero-Epiplocele — Expatriated  Omentum — Excision — 

Cure, 

5th  mo.  10th,  1828.  I  was  called  this  day,  in  con- 
sultation with  my  friend  Dr.  Janney,  to  see  the  widow 
H.,  about  sixty  years  of  age.  She  has  had  a  tumour  in 
the  right  groin  for  twenty  years,  and  says  that  she  has 
been  frequently  subject  to  colic,  which  has  generally 
been  relieved  in  a  few  hours.  Her  present  attack  oc- 
curred suddenly,  at  about  3  o'clock,  P.  M.,  on  the  7th 
inst.,  since  which  she  has  been  extremely  ill,  with  pain, 
constipation,  and  vomiting.  Her  countenance  was 
sunken  and  dejected;  her  pulse  feeble;  her  hands  and 
wrists  cool,  and  dark  coloured;  her  tongue  moist;  and 
she  had  but  little  tenderness  of  the  abdomen,  and  none 
of  the  hernial  tumour.  Her  intellect  was  clear,  and  she 
could  not  believe  that  the  tumour  in  the  groin  had  any 
thing  to  do  with  her  complaint.  However,  on  receiving 
a  very  positive  assurance  of  our  belief  that  all  her  pre- 
sent distress  was  the  result  of  incarceration  of  the 
bowel,  she  finally  consented  to  the  0[)eration.  With  the 
assistance  of  Dr.  Janney,  and  three  of  my  pupils,  I  pro- 
ceeded, between  five  and  six  o'clock,  P.  M.,  the  patient 
having  previously  taken  an  opiate.  The  tumour  was 
of  considerable  size  and  an  oval  form.  I  made  a  crucial 
incision,  dissected  up  the  flaps,  and  soon  came  down 
on  a  hernial  sac.  It  was  remarkably  thin  and  trans- 
parent. I  think  I  never  saw  one  more  so.  The  parts 
underneath   appeared  very  much  like  intestine,  and 


140  ENTERO-EPIPLOCELE. 

although  I  had  previously  expressed  the  opinion  that 
the  hernia  would  prove  to  be  entero-epiplocele,  I  now 
really  thought  that  I  had  been  mistaken.  The  sac  was 
opened  readily.  No  fluid,  or  scarcely  any,  was  con- 
tained in  it.  On  laying  it  open  in  the  usual  manner,  a 
considerable  mass  of  old,  expatriated  omentum  was 
exposed:  but  just  as  I  had  anticipated,  there  was  no 
appearance  of  the  intestine.  I  now  opened  through  the 
crown  of  the  arch  of  omentum,  and  finally  found  a 
small  slip  of  intestine  that  had  been  completely  con- 
cealed by  the  omentum.  The  intestine  was  very  dark 
coloured,  but  entirely  free  from  cadaverous  smell.  I 
now  felt  for  the  stricture,  found  it  very  firm,  and  divided 
it  with  the  bistoury.  I  then  passed  my  finger  by  the 
side  of  the  bowel  into  the  abdomen.  I  cut  off  the  prin- 
cipal part  of  the  expatriated  omentum,  and  secured 
one  vessel  by  ligature,  but  did  not  attempt  to  return 
any  portion  into  the  abdomen.  The  patient  did  not 
lose  one  ounce  of  blood,  and  the  operation  was  com- 
pleted in  about  five  minutes.  At  the  close,  she  ap- 
peared rather  fainty.  We  put  her  to  bed,  and  placed 
pillows  under  her  knees;  directed  quietness;  one  grain 
of  opium  every  four  or  six  hours.  Two  of  my  pupils 
remained  constantly  with  this  patient — who  was  ex- 
tremely ill — and  as  will  be  perceived,  a  note  was  made 
of  her  symptoms  every  four  hours. — Nighty  12  o'clock. 
Pulse  108.  The  patient  has  been  tolerably  quiet  since 
the  operation,  and  has  slept  pretty  well  since  9  o'clock, 
when  she  took  one  grain  of  opium.  Her  bowels  have 
been  opened  two  or  three  times,  and  she  has  also  dis- 
charged flatus.  Diet  of  barley-water  and  gruel  in  small 
quantities,  and  frequently. 

11th.  Morning,  11  o'clock.     The  patient  has  awak- 


ENTERO-EPII'LOCELE.  141 

ened  from  are  freshing  sleep  of  three  hours,  nearly.  She 
is  somewhat  thirsty.  Pulse  100,  with  strength  and  ful- 
ness.— Evenings  6  o'clock.  Dr.  Janney  saw  her.  Some 
reaction  took  place  about  2  o'clock,  P.  M.,  which  was 
diminished  by  applying  cool  vinegar  to  the  face  and 
arms.  She  has  had  occasional  sleep.  She  took  a  se- 
cond grain  of  opium  at  4  o'clock.  Her  pulse  was  now 
104;  her  abdomen  tympanitic.  She  has  just  had  an 
evacuation. — 8  o'clock.  Pulse  106;  skin  natural.  She 
complains  of  a  sense  of  tightness  at  the  pit  of  the  sto- 
mach. She  has  had  some  sleep.  Directed  castor  oil  oj. 
to  be  taken  every  four  hours,  with  mint-tea. — 10  o'clock. 
Her  bowels  have  been  opened;  one  grain  of  opium  ex- 
hibited.— 11  o'clock.  Pulse  108,  and  full.  She  has  had 
another  evacuation;  is  restless,  and  not  inclined  to 
sleep. — 12  o'clock  at  night.  Pulse  120;  skin  rather  hot 
and  dry.  She  is  wakeful,  says  she  feels  faint,  and  com- 
plains of  excessive  thirst. 

12th.  Mornings  near  3  o'clock.  Pulse  124,  and  irri- 
tated. Her  bowels  were  opened  at  2  o'clock,  the  dis- 
charge was  quite  natural.  She  has  thirst,  and  dozes  at 
intervals;  skin  husky. — Near  5  o'clock.  The  last  dose 
of  oil  was  ejected.  This  medicine  was  discontinued. 
Pulse  126,  and  irritated;  tongue  furred,  and  florid  at 
the  point.  The  patient  is  very  restless. — 7  o'clock.  Pulse 
126,  and  fuller.  The  bowels  have  been  freely  opened, 
and  the  patient  is  not  quite  so  restless.  She  complains 
of  occasional  pains  in  the  epigastrium. — 9  o'clock.  Dr. 
Janney  and  myself  saw  the  patient  together,  and  exa- 
mined the  wound,  which  presented  a  favourable  aspect. 
Ordered  an  application  of  fresh  lard.  The  abdomen  is 
perfectly  soft;  pulse  120;  tongue  slightly  furred.  She 
has  had  a  copious  evacuation,  and  complains  of  insa- 


142  ENTERO-EPIPLOCELE. 

tiable  thirst.  Ordered  lime-water  and  milk  every  half 
hour,  and  sodaic  powders.  If  restless,  fifteen  drops  of 
laudanum  to  be  given.  Gum  arabic  in  solution,  as  a 
drink. — 12  o'clock,  Night.  The  patient  has  slept  well 
since  10  o'clock.  Pulse  128.  She  complains  of  uneasi- 
ness at  the  pit  of  the  stomach, 

13th.  Dr.  Janney  saw  the  patient.  Pulse  132;  tongue 
furred  and  dry;  thirst  very  great.  Flatus  discharged 
from  the  bowels.  There  is  slight  tenderness  at  the  um- 
bilicus. The  uneasiness  at  the  epigastrium  continues. 
The  patient  states  that  she  had  been  affected  with  faint- 
ness,  and  a  disposition  to  vomit,  for  a  week  previous 
to  her  attack.  A  mixture  of  camphorated  spirits  and 
tincture  of  opium  was  ordered  to  be  applied  warm,  on 
flannel,  to  the  stomach. — Evenijig^  4  o'clock.  Pulse  the 
same.  The  patient  is  very  restless.  She  took  fifteen 
drops  of  laudanum. — 6  o'clock.  Pulse  130.  She  has 
has  had  a  little  sleep,  and  copious  natural  evacuations. 
Half  past  7  o'clock.  Dr.  Janney  and  myself  saw  the 
patient  together.  Pulse  130;  tongue  furred,  but  moist; 
tenderness  of  the  epigastrium  upon  pressure;  the  thirst 
continues.  Directed  fifteen  or  thirty  drops  of  laudanum 
according  to  the  restlessness,  every  four  or  six  hours. 
A  blister  to  the  epigastrium.  Neutral  mixture  to  be 
given  every  two  hours,  if  the  pulse  continues  high,  and 
skin  hot.  Chicken-water — 9  o'clock.  The  blister  ap- 
plied, and  the  neutral  mixture  given. — Near  10  o'clock. 
Fifteen  drops  of  laudanum  given. 

14th.  Mornings  past  3  o'clock.  Skin  hot  and  dry; 
tongue  furred  and  dry;  pulse  135.  She  has  slept  well 
for  about  an  hour. — 7  o'clock.  The  patient's  condition 
has  been  pretty  uniform  since  half  past  4  o'clock  this 
morning.     Pulse  between  111  and  113;  tongue  moist; 


ENTERO-EPIPLOCELE.  143 

skin  less  hot.  She  passes  her  urine  freely,  and  says  that 
the  uneasy  sensation  at  the  epigastrium  has  left  her. 
The  abdomen  is  soft,  and  there  is  no  more  pain  on 
pressure  than  usual.  She  has  had  two  evacuations. — 
Half  past  8  o'clock.  Dr.  Janney  and  myself  saw  the 
patient.  Pulse  112;  the  abdomen  soft;  the  wound  looks 
well;  tongue  somewhat  dry,  but  disposed  to  clean  at 
the  tip;  skin  rather  warm. — Evening,  4  o'clock.  The 
patient  is  quite  comfortable.  She  has  slept  tolerably 
well  at  intervals,  and  complains  of  no  uneasiness  at  the 
epigastrium.  Tongue  and  skin  as  before;  pulse  113. 
7  o'clock,  P.  M.  Dr.  Janney  and  myself  called  to  see 
the  patient.  Pulse  120.  The  thirst  continues.  She  com- 
plains chiefly  of  her  uneasy  position.  Directed  rennet- 
whey,  &c. 

15th.  Morning,  4  o'clock.  The  patient  passed  the 
night  quite  easily  and  composedly,  sleeping  almost  con- 
stantly after  12  o'clock.  She  has  taken  the  neutral  mix- 
ture and  the  rennet-whey.  She  has  had  no  discharge 
from  the  bowels.  Pulse  112.  No  pain  on  pressure.  No 
change  in  tongue  or  skin. — Half  past  8  o'clock.  Pulse 
106.  Directed  castor  oil  oss.  every  four  hours,  which 
produced  a  free  and  natural  evacuation. — Eveiiing, 
half  past  4  o'clock.  An  exacerbation  of  fever  came  on. 
7  o'clock.  Dr.  Janney  and  myself  called.  Found  the 
abdomen  soft,  and  the  tongue  partly  cleaned.  Thirst 
diminished.  Directed  some  nourishment,  and  the  omis- 
sion of  the  saline  mixture,  unless  the  skin  is  hot  and 
dry.  To  commence,  early  in  the  morning,  with  an  in- 
fusion of  serpentaria  and  chamomile,  a  small  wine- 
glassful  to  be  taken  every  hour. 

16th.  Morning,  8  o'clock.  Pulse  108;  tongue  clean 
and  moist.  The  patient  passed  a  comfortable  night.  She 


144  ENTERO-EPIPLOCELE. 

took  twenty  drops  of  laudanum. — Evening,  7  o'clock. 
Pulse  and  tongue  in  the  same  condition.  Every  symp- 
tom favourable.  She  has  had  a  free,  natural  evacua- 
tion without  medicine,  and  has  a  desire  for  food,  such 
as  asparagus,  &c. 

17th.  Morning,  8  o'clock.  Pulse  100;  tongue  as  yes- 
terday. The  patient  passed  the  night  comfortably  with- 
out laudanum. — Evening.  She  is  still  in  the  same  con- 
dition. 

18th.  Pulse  106;  tongue  as  before.  The  patient  rested 
well,  and  had  a  free  evacuation  this  morning.  She  had 
taken  a  spoonful  of  oil  at  bed  time.  The  infusion  of 
chamomile  and  serpentaria  was  rejected  by  the  sto- 
mach this  morning,  and  was  therefore  omitted.  Ordered 
infusion  of  columbo  and  orange  peel,  a  wdne-glassful 
every  two  hours.  The  granulations  in  the  wound  ap- 
pear white  and  not  healthy.  Directed  bark  to  be  sprin- 
kled on  them. 

19th.  The  patient  says  she  feels  well.  Pulse  96. 
Tongue  natural. 

20th.  Morning.  Her  bowels  are  free. — Evening.  Pulse 
100.  Her  medicine  has  not  agreed  with  her  stomach. 
Ordered  infusion  of  bark,  a  wine-glassful  every  two 
hours,  to  be  taken  early  in  the  morning. 

21st.  Pulse  96.  The  patient  rested  well.  Her  bowels 
were  moved  at  12  o'clock. — Evening.  Pulse  80,  and 
every  thing  favourable. 

6th  mo.  4th.  The  patient  has  been  doing  well  since 
the  last  date,  and  to-day  the  ligature  came  away  by 
twisting  it.     This  patient  recovered  completely. 

Remark. 
The  unpleasant  symptoms  in  this  case  may  have  been 


ENTEKO-EPIPLOCELE.  145 

produced  by  the  ligature;  but  on  this  point  my  opinion 
is  not  decided. 

It  is  a  source  of  reocret  to  observe  a  number  of  writers, 
some  of  them  of  the  highest  character,  all  following  in 
the  same  train;  all  recommending  the  practice  of  ex- 
cising the  omentum,  and  applying  ligatures  to  the 
bleeding  vessels,  without  giving  one  instance  to  prove 
the  safety  of  the  plan.  Is  there  not  a  danger,  by  this 
course,  of  a  proposition,  vague  in  the  first  instance,  be- 
ing converted  by  frequent  repetition  into  a  settled  rule 
of  practice,  until  melancholy  experience  may  prove  its 
unsoundness  and  danger? 

The  question  then  arises,  what  is  to  be  done  with 
expatriated  omentum?  If  a  small  portion  presents  itself, 
and  can  be  conveniently  cut  off,  no  danger  need  be 
apprehended  from  hemorrhage;  but  when  a  large  mass 
is  encountered,  it  has  generally  been  my  practice  to 
allow  it  to  remain  undisturbed. 

The  following  cases  furnish  examples  of  this  condi- 
tion of  the  omentum,  and  of  the  treatment  to  be  pur- 
sued. 


CASE  XXIV. 


Entero-Epiploccle — Exjmtriated  Omentum — Excision — 

Cure. 

lOth  mo.  28th,  1826.  I  was  called  this  day  in  consul- 
tation Avith  Dr.  Ruan,  to  see  the  wife  of  A.  S.  The 
patient  is  about  thirty-six  years  of  age.  About  seven 
years  ago,  after  a  great  etTort  in  lifting,  she  became 

19 


146  ENTERO-EPIPLOCELE. 

affected  with  a  femoral  hernia  on  the  left  side.  The 
protruded  parts  have  never  been  completely  reduced 
since  that  time.  She  has  had  several  spells  of  colic,  as 
she  calls  it,  with  an  increase  in  the  size  of  the  tumour, 
but  they  have  always  gone  off,  until  the  present  attack, 
which  has  had  forty-eight  hours  continuance.  The 
tumour  is  pretty  large. 

Dr.  Ruan  was  called  last  evening.  He  bled  her  ad 
deliquium,  and  attempted  the  taxis.  He  says  that  there 
was  a  considerable  reduction  in  the  size  of  the  tumour 
in  consequence  of  this  attempt.  Laxative  injections 
were  given,  and  he  ordered  an  opiate  enema;  but  it 
seems  that  she  passed  a  most  wretched  night.  She  has 
vomited  up  every  thing  from  the  commencement  of  the 
attack;  and  her  bowels  are  obstinately  confined.  I 
found  her  in  great  distress,  with  extreme  tenderness  in 
the  tumour,  and  in  the  abdomen;  complaining  of  severe 
pain  in  the  stomach,  extending  toward  the  bottom  of 
the  abdomen.  The  pain  appeared  to  come  on  in  pa- 
roxysms, during  which  she  suffered  excessively.  She 
rejects  anodynes  given  by  the  mouth,  and,  what  is  truly 
remarkable,  anodyne  injections  pass  away  from  her  im- 
mediately. 

The  operation  was  proposed,  and  Drs.  Physick  and 
Barton  were  called  in  consultatiou.  We  gave  her 
opium  by  the  rectum,  and  tried  some  in  the  form  of 
pill.  We  then  prepared  for  the  operation,  which  I  per- 
formed about  fifty-two  hours  after  the  commencement 
of  the  strangulation,  assisted  by  my  medical  friends. 

The  patient  was  placed  on  a  table.  By  flexing  the 
thigh  on  the  pelvis,  it  was  found  that  the  skin  over  the 
tumour  was  quite  flaccid.  Dr.  Physick  aided  in  pinching  it 
up,  and  I  then  passed  the  sharp-pointed  bistoury  through 


ENTERO-EPIPLOCELE.  147 

it,  with  the  back  of  the  instrument  turned  toward  the 
tumour,  and,  at  one  stroke,  made  a  longitudinal  incision 
nearly  long  enough  for  my  purpose.  1  did  not  make 
a  crucial  incision  in  this  case.  By  the  aid  of  the  director 
and  bistoury  I  soon  laid  bare,  as  we  supposed,  the  her- 
nial sac;  and,  pinching  up  a  small  portion  with  the  dis- 
secting forceps,  cautiously  made  an  opening  into  it. 
What  appeared  to  be  the  sac  was  then  laid  open  in  the 
usual  manner;  but  there  was  still  a  thin  layer,  resem- 
bling cellular  membrane,  laying  over  the  strangulated 
parts.  This  was  opened  in  the  same  manner,  and 
then,  for  the  first  time,  a  small  quantity  of  fluid  escaped. 
The  omentum  was  now  exposed  to  view,  and,  on-  turn- 
ing it  aside,  a  small  slip  of  intestine,  of  a  dark  choco- 
late colour,  appeared;  hut  there  was  no  cadaverous  smell. 
I  passed  down  my  finger,  and  feeling  a  very  tight  stric- 
ture, I  very  carefully  divided  it  in  a  direction  upward 
and  a  little  inward,  with  my  blunt-pointed  bistoury, 
which  was  guarded  as  usual,  with  a  rag  wrapped  round 
the  greater  part  of  the  blade. 

I  now  returned  the  intestine  into  the  abdomen;  but 
what  was  to  be  done  with  the  omentum?  I  remarked 
to  my  friends  that  it  had  been  so  long  expatriated  that 
I  should  be  afraid  to  put  it  into  the  belly.  It  was, 
therefore,  determined  to  cut  the  greater  part  of  it  away, 
which  I  did,  removing  also,  in  the  same  manner,  a  por- 
tion of  the  old  sac,  M'hich  stuck  up  in  the  wound  like  a 
piece  of  buckram.  There  was  but  little  bleeding.  I 
pushed  the  remaining  portion  of  the  omentum  towards 
the  opening  from  the  abdomen,  hoping  that  it  would 
inflame,  and  plug  up  the  aperture,  so  as  to  form  a  natu- 
ral truss. 

Just  before  the  completion  of  the  operation,  the  wound 


148  ENTERO-EPIPLOCELE. 

was  suddenly  filled  with  what  at  first  appeared  to  be 
blood;  but,  on  closer  inspection,  it  proved  to  be  nothing 
more  than  the  same  kind  of  fluid  usually  contained  in 
the  sac,  which,  mixing  with  a  httle  blood  from  the 
omentum,  really  gave,  at  first,  the  idea  of  considerable 
hemorrhage. 

Two  sutures  were  used  in  dressing  the  wound,  leav- 
ing a  small  opening  between  the  edges,  at  its  most 
dependant  part.  The  patient  was  placed  on  her  back, 
in  bed,  with  her  knees  bent  and  supported  by  pillows. 
One  grain  of  opium  was  given,  and  directed  to  be  re- 
repeated  every  four  or  six  hours,  according  to  her  rest- 
lessness. 

Evening.  I  saw  her  between  five  and  six  o'clock,  and 
again  after  ten  o'clock  to-night.  She  is  greatly  relieved 
from  pain,  although  she  still  has  some  slight  paroxysms. 
She  has  considerable  thirst,  and  vomits  occasionally, 
after  drinking.  She  attributes  the  sickness  to  the  opium, 
which,  she  says,  always  disagrees  with  her.  She  takes 
barley-water.  Her  pulse  is  100  in  the  minute.  The  tem- 
perature of  her  skin  is  nearly  natural,  and  her  tongue 
is  slightly  furred.  She  has  less  pain  on  pressure,  in  her 
abdomen.  Her  countenance  and  spirits  appear  good. 
Directed'fifteen  drops  of  the  black  drop  every  four  or 
six  hours,  if  restless;  but,  if  composed,  the  anodyne  to 
be  omitted. 

29th.  Morning,  9  o'clock.  The  patient  slept  well 
through  the  night.  Her  countenance  is  good;  pulse  80, 
soft  aud  full;  abdomen  flaccid,  and  its  tenderness  greatly 
diminished.  Directed  half  a  pint  of  boiling  water  to  be 
poured  on  sup.  tart,  potass.  Sss.  et  manna  ij.  A  table- 
spoonful  to  be  given  frequently  till  it  operates;  and  in 
case  of  pain,  fifteen  drops  of  the  black  drop  to  be  also 


ENTERO-EPIPLOCELE.  149 

given. — Evening,  5  o'clock.  As  I  was  absent  from  the 
city,  Dr.  Barton  saw  the  patient  for  me.  Her  abdomen 
was  tumid  from  distension  of  the  bladder.  The  catheter 
was  introduced,  and  a  large  quantity  of  urine  drawn  off. 
Pulse  and  skin  natural.  The  dose  of  crem.  tartar  and 
manna  was  increased  to  a  wine-glassful,  with  directions 
that  if  it  did  not  operate  by  10  o'clock,  she  should  take 
a  wine-glassful  of  an  infusion  of  senna  -every  hour. 

30th.  Morning,  10  o'clock.  Dr.  Barton  again  visited 
the  patient.  The  crem.  tartar  produced  great  pain  in 
the  bowels,  followed  by  an  evacuation  at  i  past  9 
o'clock  last  evening,  and,  as  she  was  restless,  fifteen 
drops  of  black  drop  were  given  her  at  10  o'clock.  She 
rested  well  through  the  night.  Her  pulse  and  skin  this 
morning  showed  some  slight  febrile  excitement.  Her 
retention  of  urine  still  continued,  but,  as  there  was  no 
desire  to  evacuate  it,  the  catheter  was  not  introduced. 
Serum,  slightly  tinged  with  blood,  is  discharged  from 
the  wound;  this  is  supposed  by  Dr.  Barton  to  come  from 
the  cavity  of  the  abdomen.  The  Doctor  directed  a 
bread-and-milk  poultice  to  be  applied  over  the  wound, 
and  that  her  diet  should  be  barley-water. — Evening,  8 
o'clock.  Dr.  Ruan  and  myself  visited  the  patient  this 
evening.  Pulse  80;  skin  natural.  I  drew  off  the  urine 
with  the  catheter.  The  patient  passes  flatus  freely. 

31st.  Morning,  9  o'clock.  The  patient  has  passed  a 
very  good  night,  except  that  she  was  troubled  with 
flatulency.  Pulse  88;  skin  and  countenance  natural. 
There  has  been  no  evacuation  from  the  bowels  since 
last  report.  I  directed  her  to  take  an  ounce  of  castor 
oil,  and  to  drink  oatmeal-gruel.  The  catheter  has  to  be 
used  regularl}^,  morning  and  evening. — Evening,  8 
o'clock.  The  patient  has  not  yet  had  any  evacuation. 


150  ENTERO-EPIPLOCELE. 

11th  mo.  2d.  The  tenderness  of  the  abdomen  is  nearly 
gone.  Directed  castor  oil  ^i">  ^^^  for  diet,  oatmeal- 
gruel,  tapioca,  &c. 

3d.  Pulse  80,  soft  and  full;  tongue  clean;  skin  natural. 
The  wound  has  partly  healed  by  the  first  intention,  and 
the  remainder  is  suppurating.  The  patient  is  permitted 
to  lie  on  her  side,  and  to  eat  the  soft  part  of  an  oyster 
every  hour. 

4th.  Pulse  80;  skin  natural;  tongue  clean.  The  pa- 
tient has  had  three  evacuations  since  the  last  report. 
The  abdomen  is  flaccid,  and  entirely  free  from  pain  on 
pressure.  This  patient  perfectly  recovered. 


CASE  XXV. 


Strangulated   Femoral    Hernia — Dark   and  hardened 
Omentum — Excision — Cure. 

11th  mo.  29th,  1823.  A  poor  widow,  aged  about 
sixty-four  years,  was  attacked  about  a  week  ago,  with 
strangulated  hernia,  which  was  regarded  by  her  medical 
attendant  as  colic,  until,  finding  his  remedies  fail,  he 
was  led,  after  several  days,  to  make  a  closer  investiga- 
tion of  the  case;  when  he  discovered  a  tumour  in  her 
left  groin. 

I  saw  her,  for  the  first  time,  yesterday  afternoon  and 
evening.  Her  stomach  had  been  retentive  for  two  days 
previously;  it  even  retained  castor  oil  very  well;  but  her 
bowels  were  obstinately  constipated.  There  was  no 
tension  or  unusual  tenderness  of  the  belly,  although  she 
complained  of  pain  and  distress  high  up  in  the  abdo- 


ENTERO-EPIPLOCELE. 


151 


men.  Her  pulse  was  rather  frequent;  but  her  tongue 
and  countenance  had  not  an  unfavourable  appearance. 
At  our  last  visit  in  the  evening,  the  patient  seemed  to 
expect  an  evacuation  from  the  bowels,  and  we  concluded 
to  exhibit  some  castor  oil,  with  an  opiate,  and  to  leave 
the  case  till  morning. 

On  visiting  her  this  morning,  we  found  that  she  had 
vomited  the  oil,  and  her  whole  aspect  was  more  unfa- 
vourable. I  therefore  gave  her  an  opiate,  and  proceeded 
to  the  operation,  assisted  by  Drs.  Uhler  and  Hewson. 
The  tumour  was  rather  large  for  a  femoral  hernia.  I 
made  a  crucial  incision,  dissected  back  the  corners,  and 
divided  the  layers  of  fascia3  with  considerable  expedition, 
by  the  aid  of  the  director,  assisted  occasionally  by  the 
handle  of  the  scalpel.  The  sac  was  opened  in  the  usual 
manner,  and  a  small  portion  of  bloody  fluid  escaped. 
On  enlarging  the  orifice,  some  very  dark-coloured  and 
hard  omentum  came  into  view,  one  portion  of  which 
felt  almost  like  bone;  but  no  intestine  was  apparent.  I 
turned  aside  the  omentum,  and  then  discovered  a  small 
portion  of  very  dark-coloured  bowel.  As  the  omentum 
was  considerably  in  the  way,  I  cut  it  off.  It  did  not 
bleed,  and  yet  there  was  not  the  least  cadaverous  smell 
from  the  sac.  On  examining  the  stricture,  it  was  found 
very  firm.  I  very  cautiously  divided  it  with  the  blunt- 
pointed  bistoury,  until  I  could  pass  my  finger  into  the 
abdomen.  It  was  now  found  that  the  omentum  about 
the  stricture  was  firmly  adherent  to  the  intestine. 
With  my  finger,  I  cautiously  separated  the  adhe- 
sions, and  returned  the  parts  into  the  abdomen.  I  also 
separated  some  adhesions  within  the  cavity.  The  wound 
was  dressed  with  adhesive  strips.  The  patient  bore  the 
operation  well. 


152  ENTERO-EPIPLOCELE. 

Evening.  The  patient  presents  rather  a  discouraging 
appearance.  Her  countenance  is  more  sunken,  and  her 
tongue  somewhat  dark.  She  has  slept  almost  constantly 
since  the  operation.  Pulse  firm,  about  100.  There  is 
still  great  uneasiness  in  the  abdomen,  with  weakness 
of  stomach,  and  considerable  inclination  to  vomit.  The 
bowels  have  not  been  opened. 

30th.  Morning.  Pulse  100,  full  and  soft;  temperature 
natural;  tongue  moist,  furred,  and  less  dark;  counte- 
nance improved.  The  patient  vomited  twice  during 
the  night,  and  also  discharged  flatus  per  anum  twice. 
She  slept  well,  but  still  complains  of  pain,  and  a  sense 
of  fulness  in  the  stomach  and  abdomen.  She  took  one 
grain  of  opium,  and  three-fourths  of  a  Seidlitz  powder, 
during  the  night.  Directed  one-fourth  of  a  Seidlitz 
powder  to  be  taken  every  half  hour. — Evening.  Pulse 
112,  less  full  and  regular.  The  patient  has  slept 
considerably,  has  vomited  twice,  and  has  had  one  fecal 
discharge.  The  pain  in  the  abdomen  continues. 

12th  mo.  1st.  The  patient  has  had  five  evacuations. 
She  took  one  grain  of  opium  since  last  visit.  Pulse  100; 
tongue  moist.  Pressure  on  the  abdomen  gives  her  pain, 
but  the  belly  is  flaccid. — Evening.  Pulse  96;  tongue 
furred;  no  tension  of  the  abdomen.  The  last  stool  took 
place  about  9  o'clock  this  morning.  The  Seidlitz  pow- 
der has  been  given  regularly,  and  the  patient  has  taken 
one  grain  of  opium.  She  complains  of  great  pain  about 
the  umbilicus.  Ordered  to  continue  the  Seidlitz  powder 
until  the  bowels  are  moved,  and  to  take  a  grain  of 
opium  every  six  hours,  if  restless. 

2d.  Pulse  100;  tongue  somewhat  dark  and  dry;  face 
flushed;  some  tension  of  the  abdomen,  but  no  pain.  The 
patient  complained  of  difficulty  in  passing  urine,  and  the 


ENTEllO-EPll'LOCELli.  153 

catheter  was  introduced.  Ordered  to  omit  the  opium 
and  continue  theSeidhtz  powder. — Evening.  Pulse  112; 
tongue  moist;  skin  natural;  tension  and  pain  in  the  ab- 
domen; no  stool.  Ordered  castor  oil,  a  table-spoonful 
every  two  hours,  and  an  opiate,  if  restless. 

3d.  Pulse,  tongue,  and  skin  continue  in  the  same 
state.  The  patient  vomited  once  in  the  night,  passes 
urine  freely,  and  has  had  natural  stools.  The  abdomen 
is  less  tense,  but  is  still  painful.  Treatment  continued. 
Evening.  The  patient  has  passed  a  considerable  amount 
of  flatus,  but  has  had  no  stool.  The  pain  in  the  abdo- 
men slight.  Treatment  continued,  and  an  enema  of 
flaxseed-tea  directed. 

4th.  Pulse  100;  skin  natural;  tongue  somewhat  dry. 
The  patient  has  had  three  stools.  The  pain  and  tension 
of  the  abdomen  slight.  Treatment  continued.  Ordered 
a  diet  of  chicken-water,  whey,  &c.  The  wound  dressed 
with  simple  cerate. 

5th.  Pulse  112;  skin  and  tongue  as  at  last  visit.  The 
patient  has  had  about  five  discharges  from  the  bowels. 
The  tension  of  the  abdomen  is  diminished,  but  the  pain 
continues.  Ordered  to  omit  the  oil,  but  to  continue  the 
Seidlitz  powder,  and  if  necessary,  the  opiate. — Evening. 
Tension  and  pain  diminished;  pulse  100.  The  patient 
has  had  several  stools  without  medicine.  Treatment 
continued. 

6th.  Pulse  100;  skin  natural;  tongue  rather  dark 
and  dry;  slight  pain  in  the  umbilical  region;  very  little 
tension  of  the  abdomen.  The  patient  had  one  stool 
last  evening.  She  rested  well  through  the  night.  The 
wound  is  suppurating  moderately.  Ordered  the  Seid- 
litz powder  to  be  taken  three  times  a  day.  Treatment 
and  regiincn  continued. 

20 


154  ENTERO-EPIPLOCELE. 

7th.  Pulse  100;  the  tension  and  pain  have  ceased; 
the  bowels  act  freely.    Treatment  continued. 

8th.  Pulse  90;  wound  suppurating  moderately.  Every 
thing  looking  favourably.    Treatment  continued. 

This  patient  recovered  perfectly. 


CASE  XXVI. 

Irreducible  Enter o-Epiplocele — Stercoraceous  Vomiting 

Operation — Death. 

2d  mo.  15th,  1819.  I  was  called  by  Dr.  Dewees  to 
see,  with  him,  a  widow  lady  aged  sixty-seven  years. 
She  had  been  afflicted  with  hernia  since  the  birth  of  her 
first  child,  which  must  have  been  many  years  ago.  She 
represented  that  she  had  always,  since  that  time,  had  a 
tumour  in  the  part,  which  was  generally  about  the  size 
of  an  Ggg,  but  sometimes  larger.  She  had  been  labour- 
ing under  strangulation  since  the  evening  of  the  tenth 
instant,  when,  in  a  fit  of  coughing,  the  part  became 
strangulated.  Dr.  Dewees  had  ascertained  the  existence 
of  hernia,  a  few  hours  before  I  was  called,  and  imme- 
diately requested  a  consultation.  On  examination,  at 
this  time,  he  found  the  matter  which  she  had  thrown 
from  her  stomach,  stercoraceous. 

On  my  first  visit  I  was  struck  with  the  peculiar  situa- 
tion of  the  tumour.  It  appeared  to  be  in  the  upper  part 
of  the  thigh,  extending  across  it,  and  I  could  trace  it 
along  the  internal  abdominal  ring,  as  is  usual  in  ingui- 
nal hernia.    I  was  strongly  inclined  to  believe  that  it 


ENTERO-EPIPLOCELE.  155 

was  femoral,  but  the  size  of  the  tumour  exceeded  that 
of  any  femoral  hernia  I  had  ever  seen  before. 

After  dehberating  on  the  case,  Dr.  Dewees  and  my- 
self concluded  to  recommend  the  operation  at  once^  and 
it  was  most  readily  submitted  to  by  the  patient.  An 
anodyne  enema  was  given,  and  two  grains  of  opium 
were  administered  by  the  mouth.  At  this  time  the  pa- 
tient had  a  tolerably  good  pulse,  and  no  cold  or  clammy 
sweats;  her  tongue  was  rather  dark;  and  her  bowels 
somewhat  tender  to  the  touch. 

I  made  a  crucial  incision  through  the  integuments, 
and  dissected  up  the  four  flaps;  then,  principally  by  the 
aid  of  the  grooved  director,  I  divided  several  layers  of 
fascia,  and  after  dissecting  carefully  downward,  I  at 
last  opened  the  sac,  and  exposed  a  large  mass  of  omen- 
tum. I  found  considerable  difficulty  in  this  part  of  the 
operation,  in  consequence  of  there  being  no  fluid  be- 
tween the  sac  and  the  omentum.  After  I  had  fairly  un- 
covered the  omentum,  still  greater  difficulties  assailed 
me;  for  I  found  this  mass  firmly  impacted  together  by 
pretty  strong  bands  of  adhesion:  there  was  no  appear- 
ance of  intestine.  I  had  no  doubt  of  the  existence  of 
strangulated  bowel,  but  the  question  was,  where  to  find 
it;  and  I  concluded  that  the  only  way  to  get  at  it  was 
to  lay  open  the  omentum.  After  having  penetrated  for 
some  depth  through  the  centre  of  the  mass,  I  at  last 
found  an  aperture,  through  which  I  pushed  my  finger, 
and  felt  the  bowel,  contained  as  it  were,  in  another  sac. 
I  now  dissected  through  the  omentum  more  freely,  and 
brought  a  portion  of  intestine  into  view.  It  was  of  a 
very  dark  colour.  Some  fluid,  of  a  bloody  colour,  was 
contained  in  this  inner  sac,  hut  it  was  free  from  the  cada- 
verous smell  of  a  mortified  part.     I  pushed  my  finger 


156  ENTERO-EPIPLOCELE. 

down  by  the  side  of  the  bowel  and  felt  a  stricture,  which 
I  divided  inwards,  in  a  direction  towards  the  pubis,  and 
pretty  readily  returned  the  bowel  into  the  abdominal 
cavity. 

The  vomiting  ceased,  and  her  distress  left  her  im- 
mediately afterwards,  yet  her  strength  gradually  de- 
clined. She  was  much  disposed  to  coma.  Surgical 
aid,  in  this  case,  came  too  late;  for,  though  the  patient 
was  certainly  relieved  by  the  operation,  in  forty-eight 
hours  afterwards  she  died.  The  omentum  was  per- 
mitted to  remain  where  we  found  it.  No  post  mortem 
examination  took  place. 


CASE  XXVII. 


Irreducible  Enter o-Epiplocele — Stercoraceoiis  Vomiting — 
Operation — Intestine  black — Death, 

11th  mo.  20th,  1822.  I  was  called  this  day,  in  con- 
sultation with  Drs.  Griffith  and  Hewson,  to  see  the 
Widow  L.,  an  elderly  woman  who  had  been  affected 
with  an  irreducible  femoral  hernia  of  the  left  side,  for 
nineteen  years.  It  was  unusually  large,  and  of  an  ob- 
long shape,  extending,  I  suppose,  at  least  eight  or  ten 
inches  from  above  downward,  and  about  six  inches  in 
width.  At  its  lower  part  it  formed  an  irregular  apex. 

On  the  morning  of  the  17th  instant,  as  she  rose  from 
her  bed,  she  was  suddenly  attacked  with  severe  pain, 
and  an  additional  descent  and  sudden  strangulation 
took  place.  Immediately  after  this,  she  had  an  evacua- 


ENTERO-EPIPLOCELE.  157 

tion  from  the  bowels.  Various  attempts  were  made  by 
Drs.  Griffith  and  liewson  to  reduce  the  part,  but  with- 
out success;  and  ultimately  I  was  called  in  consultation. 

When  I  saw  the  patient,  her  countenance  was  good 
and  lively;  her  tongue  moist,  slightly  furred,  and  rather 
whitish  than  dark.  The  abdomen  was  soft  and  natural, 
and  was  very  little  sensible  to  pressure,  except  in  the 
vicinity  of  the  stricture.  The  tumour  was  painful  when 
pressed.  She  complained  of  general  distress.  Pulse 
about  130  in  the  minute.  On  examining  the  vomited 
contents  of  the  stomach,  they  were  found  completely 
stercoraceous.  This  patient  reminded  me  very  forcibly 
of  the  preceding  case.  On  examining  the  tumour,  I 
thought  I  very  distinctly  perceived  a  fluctuation.  As 
the  patient  at  once  consented  to  the  operation.  Dr. 
Hewson,  who  was  the  operator,  commenced  the  neces- 
sary preparations.  A  full  dose  of  laudanum  was  given. 

A  crucial  incision  was  made  over  the  most  promi- 
nent part  of  the  tumour,  but  was  not  extended  over  the 
whole  tumour.  After  dividing  the  integuments,  Dr.  H. 
soon  came  down  upon  a  firm  fascia,  and  there  appeared 
a  small  point,  rising  rather  above  the  general  level, 
which,  on  being  touched,  gave  the  impression  to  the 
fincer  of  a  fluctuation  underneath.  It  was  concluded 
to  open  the  sac  at  this  point,  which  was  cautiously 
done. 

The  sac  was  found  to  be  remarkably  thick.  All  the 
layers  of  fascia)  appeared  to  be  completely  identified, 
and  had  formed  an  investment  of  the  thickness  of  a 
quarter  of  an  inch.  This,  I  presume,  depended  on  the 
Ions:  continuation  of  the  disease  in  an  irreducible  form. 
When  the  sac  was  laid  open,  a  mass  of  omentum  was 
displayed,  through  which  several  small  apertures  were 


158  ENTERO-EPIPLOCELE. 

discovered,  and  through  these  apertures  passed  a  small 
portion  of  bloody-coloured  serum,  such  as  we  often 
find  in  a  hernial  sac. 

The  case  was  less  embarrassing  than  that  just  de- 
tailed, because  the  serous  and  bloody  fluid  which 
passed  through  the  apertures  in  the  omentum  clearly 
indicated  the  course  that  ought  to  be  pursued.  The 
Doctor  broke  through  the  arch  formed  by  the  omentum, 
and  brought  into  view  a  portion  of  intestine  that,  by 
candle-light^  appeared  quite  hlack  and  mortified;  but  it 
was  destitute  of  any  cadaverous  fetor.  The  stricture 
was  now  divided  directly  upward,  so  that  the  finger 
could  be  passed  into  the  cavity  of  the  abdomen,  by 
the  side  of  the  bowel;  and,  with  rather  more  difficulty 
than  common,  the  intestine  was  reduced.  The  patient 
supported  the  operation  very  well.  The  omentum  was 
permitted  to  remain  undisturbed. 

21st.  I  saw  her  again  in  consultation.  She  had 
passed  a  more  comfortable  night  than  might  have  been 
expected,  but  still  the  bowels  were  not  opened,  and 
yet  the  sufferings  of  the  patient  were  greatly  dimi- 
nished. 

22d.  We  found  her  this  morning,  in  articulo  mortis. 
She  has  had  no  evacuation  of  the  bowels  since  the 
operation. 

This  patient  lived,  contrary  to  all  expectation,  for 
several  days  longer,  but  finally  died. 


MORTIFIED  OMENTUM. 

The  several  methods  of  treatment,  which  relate  to 
the  excision  of  expatriated  omentum,  have  also  been 


ENTERO-EriPLOCELE.  159 

proposed,  when  this  part  is  in  a  state  of  mortification. 
These  have  been  so  fully  examined  in  the  preceding 
section,  that  it  is  deemed  unnecessary  to  recapitulate 
them.  Believing  that  the  excision  of  a  large  mass  of 
omentum  is  attended  with  risk  by  any  method,  I  have 
pursued  the  practice  of  leaving  the  mortified  portion 
in  the  wound,  relying  upon  the  efforts  of  nature  to  effect 
its  separation  from  the  sound  parts.  This  process  may 
be  assisted  by  the  gradual,  yet  very  gentle  pressure  of 
a  ligature  around  the  root  of  the  diseased  mass,  in 
such  a  manner  that  the  patient  may  at  any  moment 
unloose  it,  if  he  should  feel  pain  or  sickness. 

This  plan  has  been  strongly  recommended  by  Hey, 
and  pursued  by  him  successfully  in  three  cases  detailed 
in  his  valuable  work. 

A  case  fell  under  my  care  some  years  ago,  in  which 
this  practice  was  successfully  adopted.  It  was  pub- 
lished in  the  Eclectic  Repertory,  Vol.  I.  p.  13,  from 
which  it  has  been  extracted. 


CASE  XXVIIT. 

Entero-Epiplocele — Mortified  Omentum — SlougMng  of 
the  mortified  mass — Recovered. 

On  the  third  day  of  the  Third  month  (March,)  1810, 
my  immediate  attendance  in  consultation  was  requested 
by  my  friend  Dr.  Samuel  Tucker,  of  Burlington,  N.  J. 

The  patient  was  a  farmer  of  middle  age,  who  led  a 
laborious  life,  was  of  temperate  habits,  and  the  parent 
of  six  children. 


160  ENTERO-EPIPLOCELE. 

He  had  been  occasionally  afflicted  with  scrotal  her- 
nia for  fifteen  years,  but  had  never  worn  a  truss,  or 
disclosed  his  situation  to  any  person.  When  it  proved 
troublesome,  he  had  been  in  the  practice  of  reducing  it 
ivithout  difficulty. 

On  the  morning  of  the  28th  of  Second  month,  while 
in  the  act  of  lifting  a  heavy  log,  a  portion  of  the  abdo- 
minal contents  was  suddenly  protruded  through  the 
ring,  and  became  strangulated.  He  had  an  alvine  dis- 
charge immediately  after. 

From  the  period  that  Dr.  Tucker  first  saw  him,  until 
I  was  called,  he  had  diligently  resorted  to  the  most  ap- 
proved plans  of  reduction;  viz.,  taxis,  venesection, 
applications  of  ice  to  the  tumour,  tobacco  injections, 
warm  bath,  &c.  &c.,  but  all  without  effect. 

When  I  saw  him,  his  chief  distress  appeared  to  arise 
from  vomiting  and  hiccough;  the  latter  always  occurred 
after  drinking.  His  pulse  was  remarkably  tranquil; 
tongue  moist,  and  but  slightly  furred;  no  tension  or  ten- 
derness in  the  abdomen;  and  it  was  not  until  the  latter 
part  of  that  day  that  he  was  sensible  of  darting  pains, 
which  occasionally  extended  from  the  strictured  part 
towards  the  abdominal  cavity.  The  tumour  was  of  con- 
siderable size,  and  rather  firm  to  the  touch. 

As  Dr.  Tucker  had  decided  on  the  necessity  of  the 
operation  previously  to  sending  for  me,  it  only  remained 
for  us  to  obtain  the  patient's  consent;  but  this  was 
rather  difficult,  for  he  was  very  indecisive,  sometimes 
partly  consenting,  and  then  refusing.  It  was  night 
when  I  visited  him,  and  under  all  circumstances,  it  ap- 
peared as  if  nothing  could  be  done  until  daylight.  The 
mildness  of  his  symptoms  reconciled  us  more  readily 
to  this  conclusion.     He  had  slept  well  the  preceding 


ENTERO-EPIPLOCELE.  161 

night  without  an  anodyne.  A  small  enema  containing 
tincture  of  opium  was  given  him,  and  directions  were 
left  to  repeat  it  in  an  hour,  if  the  patient  should  be  rest- 
less. 

Dr.  Tucker  and  one  of  his  friends  saw  him  about 
sunrise.  He  walked  from  his  bed-chamber  into  the 
common  room,  handed  chairs,  invited  them  to  sit  down, 
said  he  had  passed  a  good  night,  and  in  fact  had  quite 
abandoned  the  idea  of  having  any  operation  performed. 

I  saw  him  soon  after;  and  we  again  endeavoured  to 
explain  to  him  the  extreme  danger  of  his  situation,  and 
he  at  last  consented  to  the  operation. 

An  opiate  was  exhibited,  and  he  was  placed  on  a 
table.  An  incision  was  made  through  the  skin,  suffi- 
ciently large  to  allow  a  free  examination  of  the  parts 
about  the  neck  of  the  hernial  sac.  While  carefully 
dissecting  through  the  integuments,  three  arteries  were 
divided  and  secured  by  ligatures;  the  largest  was  found 
running  directly  across  and  just  below  the  neck  of  the 
tumour.  Several  tendinous  stricturing  bands  were 
brought  into  view  and  divided;  but  after  every  apparent 
external  cause  of  stricture  was  removed,  the  prolapsed 
parts  were  still  irreducible.  The  incision  was  extended 
alono-  the  scrotum  nearly  to  the  bottom  of  the  tumour, 
and  the  hernial  sac  was  laid  open.  A  fluid  of  a  bloody 
colour  issued  from  it. 

It  was  now  evident  that  the  chief  seat  of  the  stricture 
was  in  the  neck  of  the  sac;  it  was  contracted  firmlv 
round  the  protruded  parts.  The  tip  of  my  finger  was 
introduced  as  a  director  for  the  blunt-pointed  bistoury, 
with  which  it  was  readily  divided. 

Its  contents  consisted  chiefly  of  omentum,  of  which 

21 


162  ENTERO-EPIPLOCELE. 

there  was  a  much  larger  portion  than  would  have  been 
imagined  from  the  size  of  the  tumour.  I  should  guess 
there  might  have  been  nearly  eight  ounces.  Along  with 
this,  and  lying  in  the  very  centre  of  the  omentum,  was 
a  portion  of  intestine,  which  passed  about  an  inch  and 
a  half  beyond  the  stricture.  It  appeared  nearly  natu- 
ral, but  the  omentum  was  in  a  very  different  state;  a 
considerable  part  of  it  was  sphacelated,  particularly  its 
exterior  surface,  which  was  quite  black,  and  its  vessels 
were  greatly  distended  with  coagulated  blood.  Some 
other  portions  were  of  a  light  mahogany  colour,  and 
were  brittle  when  placed  between  the  fingers.  The  cen- 
tral part  of  the  mass  was  chiefly  natural. 

The  intestine  was  speedily  reduced;  but  for  reasons 
to  be  hereafter  assigned,  the  omentum  was  left  in  the 
wound.  Three  sutures  were  used  in  uniting  the  lower 
part  of  the  incision,  so  as  to  close  it  as  nearly  as  was 
practicable  without  compressing  the  omentum.  Soft  and 
light  dressings  were  applied  over  the  whole. 

The  patient  appeared  faint  about  the  close  of  the 
operation;  he  was  presented  with  a  little  wine  and  wa- 
ter, but  it  was  rejected  by  the  stomach.  He  was  now 
placed  in  bed,  and  soon  sunk  into  an  easy  and  profound 
sleep.  He  was  in  this  state  when  I  left  him,  about  an 
hour  and  a  half  after  the  operation.  His  pulse  was  fuller 
and  yet  free  from  tension. 

A  very  light  diet  of  chicken-liquor,  barley-water,  &c. 
was  directed.  Also  ol.  ricini,  half  an  ounce  every  two 
hours  until  it  operated. 

In  a  letter  from  Dr.  Tucker,  he  reports: 

"  Our  patient  rested  well  the  night  after  the  opera- 
tion.   He  took  four  or  five  spoonfuls  of  castor  oil;  it 


ENTEUO-EPIPLOCELE.  163 

began  to  operate  at  four  o'clock  in  the  morning,  and 
relieved  his  bowels  five  or  six  times.  I  left  directions  in 
the  evening,  that  if  the  oil  operated  excessively,  it 
should  be  checked  by  taking  five  drops  of  laudanum. 
His  wife  gave  him  the  laudanum  about  noon  the  next 
day. 

"  Monday  evening,  5th.  His  bowels  had  not  been 
moved  since  noon.  I  directed  him  to  take  the  oil  again 
until  it  operated.  No  fever;  pulse  75. 

"  Tuesday  morning,  6th.  Rested  well  last  night;  no 
fever  or  pain;  pulse  75.  Castor  oil  has  operated  twice. 

"  Evening — the  same. 

"  Wednesday  morning.  Did  not  sleep  well  last  night. 
When  disposed  to  sleep,  started,  which  gave  him  some 
pain,  and  prevented  its  recurrence  for  some  time.  He 
does  not,  however,  appear  to  be  worse.  No  fever; 
pulse  75.  Takes  chicken-broth,  barley-water,  &c." 

On  the  11th  of  the  month  I  visited  him  in  company 
with  Dr.  Tucker.  He  was  then  perfectly  free  from  pain 
and  fever;  no  tension  or  tenderness  in  the  abdomen; 
union,  by  the  first  intention,  had  taken  place  in  the  part 
of  the  wound  approximated  by  sutures;  and  the  living 
omentum  situated  within  the  wound,  and  in  contact 
with  the  edges,  appeared  to  have  adhered  to  them,  and 
to  have  closed  the  cavity  of  the  abdomen. 

Subsequent  information  from  Dr.  Tucker  enables  me 
to  state,  that  on  the  18th  the  last  portion  of  the  un- 
sound omentum  sloughed  away,  leaving  the  living  part 
divided  into  two  distinct  portions,  suspended  from  the 
wound  by  two  necks. 

On  the  21st,  a  ligature  was  applied  to  one  half  the 
omentum,  in  the  manner  recommended  by  Hey;  viz., 


164  ENTERO-EPIPLOCELE. 

rather  slight  at  first,  and  increasing  gradually  as  the 
patient  could  bear  it.  On  the  25th  it  Avas  perfectly 
black  and  flaccid,  and  was  removed  by  scissors.  On  the 
26th  a  ligature  was  applied  to  the  remainder,  and  at 
this  time  the  wound  had  cicatrized,  except  where  the 
tumour  was  suspended  from  it.  In  both  cases  there  was 
a  considerable  oozing  of  blood  after  the  omentum  be- 
came black,  but  surrounding  the  part  with  lint  put  a 
stop  to  it.  On  the  fifth  day  from  the  application  of  the 
last  ligature  the  tumour  was  removed. 

In  about  five  weeks  after  the  operation  the  patient 
began  to  walk  about  the  house;  and  in  eight  weeks 
he  resumed  his  agricultural  avocations,  and  ploughed 
a  large  field  for  the  reception  of  Indian  corn.  Since 
this  period  he  has  enjoyed  very  excellent  health,  and 
wears  a  truss  to  guard  him  from  future  danger. 


It  has  been  urged  against  this  practice,  that  the 
sloughing  of  a  large  mass  of  omentum  may  cause  great 
derangement  of  the  parts  within  the  abdominal  cavity. 
That  the  adhesions  formed  about  the  ring,  may  draw 
the  stomach  and  arch  of  the  colon  out  of  their  natural 
position,  and  the  patient  may  ever  after  be  subject  to 
those,  afflictions  which  depend  on  a  displacement  of 
vital  organs. 

Instances  are  on  record  of  patients  who  have  been 
obliged  to  walk  with  the  body  bent  forward,  from  this 
cause;  and  who  have  been  obliged  to  take  their  meals 
in  this  posture,  to  prevent  the  immediate  rejection  of 
their  food. 

These  cases  are,  however,  exceedingly  rare,  and  are 
not  even  noticed  by  many  experienced  authors  who 


ENTERO-EPIPLOCELE.  165 

have  written  on  hernia.  Numerous  instances  of  irre- 
ducible hernia  present  themselves,  in  which  large  por- 
tions of  omentum  have  been  firmly  fixed  in  a  hernial 
sac  for  many  years,  without  producing  these  distress- 
ing consequences.  Is  it  not  rational  to  conclude,  that 
in  a  large  majority  of  cases  of  this  kind,  the  system 
exerts  that  wonderful  power  with  which  it  is  endued,  of 
eluding  difficulties,  and  becoming  inured  to  conditions 
which  a  priori  we  might  suppose  highly  injurious? 

It  is  not  intended,  however,  to  convey  the  idea,  that 
this  practice  is  entirely  free  from  objections;  but  that 
it  is  attended  with  less  risk  than  any  other  plan  which 
has  been  proposed. 


It  has  been  previously  stated,  that  a  portion  of  bowel 
frequently  descends  behind  an  irreducible  omental  rup- 
ture, and  there  becomes  strangulated.  If  the  surgeon 
should  succeed  in  reducing  the  intestine  by  taxis,  the 
omentum  which  remains  in  the  sac  may  still  be  sub- 
jected to  a  stricture,  by  which  its  vitality  will  be  de- 
stroyed. Under  these  circumstances,  an  abscess  is 
formed,  through  which  the  diseased  mass  is  discharged. 
The  inflammation  which  attends  this  process,  may 
produce  adhesions  about  the  neck  of  the  sac  by  which 
it  will  be  effectually  closed,  and  a  radical  cure  thus 
effected. 

A  case  of  this  description  fell  under  the  care  of  my 
friend  and  former  pupil.  Dr.  Thomas  Yardley.  An 
account  of  which  he  has  kindly  furnished  me  for  pub- 
lication. 


166  ENTERO-EPIPLOCELE. 


CASE  XXIX. 

Gangrenous  Omentum  discharged  by  Abscess — Radical 

Cure. 

"3<?mo.  20th,  1826.  About  noon  this  day  I  was  called  to 
visit  S.  C,  a  widow,  aged  about  thirty-five  years.  I  found 
her  complaining  of  intense  pain  in  the  cavity  of  the 
abdomen,  attended  by  stercoraceous  vomiting  and  con- 
stipation of  the  bowels.  These  symptoms  induced  me 
immediately  to  suspect  strangulated  hernia,  and  on  in- 
quiry, I  found  that,  though  unacquainted  with  the  name 
and  nature  of  a  '  rupture,'  she  had  observed  a  lump 
about  the  size  of  a  walnut  in  her  left  groin  for  the  last 
six  years,  ever  since  the  birth  of  her  youngest  child. 
She  stated  that  it  gave  her  little  or  no  inconvenience, 
except  in  damp  weather,  and  when  she  was  much  fa- 
tigued. About  three  years  since,  she  had  an  attack 
similar  to  the  present;  it,  however,  lasted  only  twenty- 
four  hours,  and  went  off  by  taking  oil,  laudanum,  &c. 
without  the  advice  or  assistance  of  a  physician. 

"  The  train  of  symptoms,  under  which  I  found  her 
suffering,  commenced  on  the  16th  instant.  She  had  been 
stooping  down,  washing  the  floor  of  the  house,  and  on 
raising  up,  was  suddenly  seized  with  a  very  violent  pain 
across  the  lower  part  of  the  abdomen.  The  rectum  was 
almost  immediately  evacuated,  and  vomiting  soon  su- 
pervened. To  allay  the  vomiting  and  relieve  the  pain, 
a  variety  of  medicines,  such  as  oil,  salts,  laudanum,  6zc. 
were  administered;  but  without  effect.  Being  in  indi- 
gent circumstances,  she  was  deterred  from  employing  a 


ENTERO-EPIPLOCELE.  167 

physician  till  the  20th  instant,  when  I,  as  one  of  the 
physicians  of  the  Northern  Dispensary,  was  desired  to 
visit  her. 

"  On  being  permitted  to  examine  the  parts,  I  found  a 
femoral  hernia  about  the  size  of  a  hen's  egg.  After 
placing  the  patient  in  a  proper  position,  I  resorted  to 
the  taxis,  and  in  a  few  minutes,  had  the  pleasure  of  feel- 
ing the  tumour  give  way,  and  a  gurgling  noise,  pro- 
duced by  the  return  of  the  intestine,  was  distinctly 
heard. 

"  The  pecuhar  and  distressing  pain  attending  a  stran- 
gulated bowel  ceased;  and  as  the  omentum  had  been 
so  long  excluded  from  the  cavity  of  the  abdomen,  I 
deemed  it  imprudent  to  prolong  the  efforts  to  restore 
it.  I  accordingly  directed  a  small  dose  of  calomel  and 
jalap,  and  left  the  patient,  with  instructions  that  she 
should  be  kept  as  quiet  as  possible. 

"  In  the  evening,  I  found  her  with  slight  fever,  but 
entirely  free  from  the  intense  pain  which  she  had  pre- 
viously complained  of.  The  vomiting  had  ceased,  but 
her  bowels  had  not  been  evacuated.  I  directed  a  set 
of  Seidlitz  powders  to  be  taken  in  divided  doses  at  in- 
tervals of  half  an  hour,  and  a  large  cathartic  injection 
to  be  administered  immediately,  and  repeated  in  an 
hour  if  it  did  not  produce  the  desired  effect. 

"  The  next  morning  the  nurse  reported  that  the  injec- 
tion produced  a  copious  discharge  from  the  bowels,  and 
that  the  patient  had  passed  a  very  comfortable  night. 

"  On  the  succeeding  morning  the  nurse  called  my 
attention  to  an  extensive  and  painful  inflammation  di- 
rectly over  the  hernial  tumour.  As  I  was  conscious 
that  no  rude  efforts  had  been  made  to  return  the  omen- 
tum, I  was  at  first  somewhat  surprised;  but  on  exam- 


168  ENTERO-EPIPLOCELE. 

ining  the  parts,  I  could  readily  perceive,  by  the  peculiar 
crepitation,  that  there  was  a  gaseous  fluid  contained 
in  the  cellular  texture  beneath;  and  feeling  satisfied 
that  it  was  derived  from  no  other  source  than  the  pro- 
truded omentum  that  still  remained  strangulated,  I  di- 
rected that  a  poultice  should  be  applied  to  the  part,  and 
placed  the  woman  in  such  a  position  as  to  relax  the 
integuments  as  much  as  possible. 

"  The  application  of  the  poultice  was,  in  a  short  time, 
followed  by  the  discharge  of  a  yellow  and  extremely 
offensive  matter;  several  pieces  of  dead  omentum  after- 
wards passed  out,  and  the  inflammation  of  the  sur- 
rounding parts  subsided.  Some  difficulty  was  expe- 
rienced in  healing  the  sinus  which  remained,  but  it  was 
effected  by  the  introduction  of  lint  dipped  in  tincture 
of  myrrh. 

"  This  woman  has  remained  ever  since  entirely  free 
from  rupture,  and  enjoys  excellent  health,  though  she 
continues  to  work  very  hard." 

INFLAMED  OMENTUM. 

A  portion  of  bowel  and  omentum  may  suddenly  de- 
scend in  the  same  sac,  and  immediately  become  stran- 
gulated. Efforts  at  reduction  failing,  an  operation  is 
resorted  to;  the  contents  of  the  sac  are  found  in  a  state 
of  high  and  recent  inflammation,  and  the  only  course 
that  presents  itself  is,  to  return  the  parts  into  the  abdo- 
men. In  doing  this,  the  patient  is  subjected  to  great  risk, 
either  from  the  subsequent  mortification  of  the  omental 
mass,  or  from  the  occurrence  of  severe  and  fatal  peri- 
toneal inflammation.  Some  years  ago  the  following 
case  occurred  to  me,  in  which  I  was  obliged  to  incur 
these  risks. 


ENTERO-EPIPLOCELE.  169 


CASE  XXX. 

Enter o-Epiplocele — Omentum    Liflamed — Return    into 

Cavity — Death. 

5th  mo.  11th,  1820.  I  was  called  in  haste  to  Bustle- 
ton,  in  consultation  with  Drs.  Worthington  and  Smith, 
to  visit  a  young  man  residing  at  the  stage-house.  I 
learned  that  on  the  morning  of  the  10th  instant,  at 
about  10  o'clock,  the  bowel  had  descended,  for  the  first 
time  in  his  life,  in  consequence  of  violent  exertion,  and 
had  immediately  become  strangulated.  The  taxis  and 
other  means  of  reduction  had  been  faithfully  tried  by 
Dr.  Worthington,  but  without  success. 

As  the  symptoms  were  urgent,  I  proposed  the  imme- 
diate resort  to  an  operation,  to  which  the  patient  as- 
sented. Pulv.  opii.  gr.  ij.  were  exhibited,  the  parts  were 
shaved,  and  he  was  placed  upon  the  table.  I  proceeded 
to  the  operation,  assisted  by  his  physicians  and  one  of 
my  pupils. 

An  incision  was  commenced  above  the  ring,  and  car- 
ried down  to  the  lower  part  of  the  scrotum;  the  dissec- 
tion was  cautiously  pursued  until  the  most  prominent 
part  of  the  sac  was  exposed.  The  sac  contained  a  small 
portion  of  fluid,  and  was  opened  without  difficulty. 
When  the  opening  was  sufficiently  enlarged  to  allow 
my  finger  to  pass,  my  first  impression  was  that  the  sac 
contained  coagulated  blood;  but  on  closer  examination, 
I  found  that  a  large  mass  of  omentum  was  closely  im- 
pacted in  a  very  small  space,  and  the  whole  of  its  exte- 
rior surface  was  studded  with  small  points  of  coagu- 

22 


170  ENTERO-EPIPLOCELE. 

lated  blood,  which  were  so  close  to  each  other  as  to 
convey  the  impression  of  the  whole  mass  being  blood, 
as  I  had  first  supposed. 

On  examining  the  omentum,  I  was  at  first  inclined  to 
the  opinion  that  it  was  mortified,  owing  to  its  very  dark 
colour',  but  on  puncturing  a  vein  on  its  surface,  blood 
escaped,  which  induced  me  to  suppose  that  it  was  not. 
To  ascertain  the  fact  more  certainly,  we  adopted  the 
plan  of  covering  the  parts  with  a  bladder  filled  with 
warm  water,  as  in  case  xv.  p.  95. 

The  bladder  was  kept  applied  for  about  twenty  mi- 
nutes, when  it  was  perfectly  evident  that  the  circulation 
was  going  on,  and  that  the  omentum  was  highly  in- 
flamed. A  small  portion  of  intestine  was  strangulated; 
its  colour  was  very  dark,  but  we  did  not  consider  it  in  a 
state  of  gangrene.  After  dividing  the  stricture,  the 
bowel  was  readily  returned.  But  the  disposal  of  the 
omentum  was  now  to  be  considered;  this  part  had  cer- 
tainly suffered  great  contusion  from  some  cause  or 
other.  I  was  inclined  to  believe  that  the  eflforts  at  taxis 
might  have  caused  the  efliision  of  blood  upon  the  sur- 
face of  the  omental  ball — on  the  same  principle  that 
water  is  pressed  from  a  sponge,  when  it  is  forcibly 
grasped  in  the  hand. 

To  cut  oflf  this  mass  in  its  vascular  and  inflamed 
condition,  would  subject  the  patient  to  very  great  ha- 
zard from  hemorrhage,  after  its  return  into  the  abdo- 
men, unless  ligatures  had  been  applied  to  arrest  it; 
while  the  ligatures  would,  in  my  judgment,  more  cer- 
tainly induce  fatal  peritonitis,  than  the  return  of  the 
inflamed  mass.  Besides,  it  was  not  probable  that  the 
excision  of  that  portion  which  presented  externally, 
would  prevent  the  extension  of  inflammation  to  the 


ENTERO-EPIPLOCELE.  171 

parts  within.  To  allow  a  living  inflamed  mass  to  re- 
main in  the  wound,  as  in  a  case  of  mortified  omentum, 
appeared  very  objectionable. 

It  was  therefore  concluded,  that  its  return  into  the 
abdominal  cavity,  although  manifestly  attended  with 
great  danger,  would  subject  the  patient  to  less  risk  than 
any  other  method.  To  effect  this,  the  opening  at  the 
ring  was  enlarged,  and  the  part  readily  restored.  The 
wound  was  not  drawn  together  as  usual,  by  strips  and 
sutures,  but  dressed  very  lightly  with  simple  cerate. 

I  left  the  case  under  the  full  conviction  that  dan- 
gerous inflammation  would  ensue;  and  advised  my  me- 
dical friends  to  allow  the  patient  to  rest  for  a  few  hours, 
to  recover  from  the  fatigue  of  the  operation;  and  if  reac- 
tion occurred,  to  pursue  a  rigid  antiphlogistic  course. 
It  was  agreed  to  keep  the  bowels  open  with  castor  oil, 
and  to  restrict  his  diet  to  barley-water. 

I  received  regular  accounts  from  Dr.  Smith  of  the 
progress  of  the  case. 

Soon  after  the  operation,  he  became  delirious  and 
feverish,  symptoms  of  peritonitis,  followed  by  singultus, 
supervened,  and  he  died  on  the  evening  of  the  21st  inst,, 
ten  days  after  the  operation. 

Dissection, 

On  opening  the  abdomen  and  pelvis,  the  commence- 
ment of  the  colon  presented  a  very  dark  appearance  for 
the  space  of  about  six  inches,  and  at  one  point  it  was 
quite  black.  The  coats  of  the  bowel  were  abraded 
in  several  places,  and  at  several  spots  small  sloughs 
had  separated,  so  that  flatus  rushed  out  on  handling 
the  surrounding  bowel.  The  other  parts  of  the  bowels 
appeared  nearly  natural. 


172  ^  ENTERO-EPIPLOCELE. 

That  portion  of  omentum  which  had  been  return- 
ed, was  still  inflamed,  and  adhered  in  a  solid  mass 
to  the  surrounding  parts.  No  appearance  of  gangrene 
was  discovered  in  any  part  of  the  omentum,  though  the 
parts  around  the  returned  portion  were  slightly  in- 
flamed. 

The  pelvis  contained  about  a  pint  of  turbid  fluid, 
resembling  pus  diluted  with  water,  and  slightly  tinged 
with  blood.  No  unpleasant  odour  was  observed  in  any 
part  of  the  examination. 


CHAPTER  VII. 


CONCEALED  HERNIA. 


Every  candid  practitioner,  who  has  had  much  expe- 
rience in  the  treatment  of  hernia,  will  admit  that  cases 
of  a  very  dangerous  character,  are  sometimes  involved 
in  great  obscurity,  and  may  elude  his  vigilance. 

Hence  the  utmost  caution  is  required  to  detect  those 
concealed  cases,  which,  under  the  common  form  of  co- 
lic, may  continue  unsuspected,  until  the  death  of  the 
patient,  followed  by  a  post  mortem  examination,  reveals 
the  true  state  of  the  case. 

Having  had  a  share  of  painful  experience  in  this  form 
of  the  disease,  I  have  been  led  to  increased  minuteness 
in  my  examinations,  and  have  been  enabled  to  afford 
relief  by  an  operation,  in  several  cases,  which  would 
probably  have  escaped  detection,  had  I  not  been  par- 
ticularly watchful. 

The  most  common  seat  of  mischief,  in  these  cases, 
is  at  the  internal  ring.  The  principal  part  of  a  protruded 
intestine  may  be  returned  by  taxis,  and  yet  a  very  small 
portion  may  be  detained  at  the  internal  ring,  forming  a 
very  slight  prominence  or  fulness  at  this  point,  scarcely 
observable,  and  yet  sufficient  to  keep  up  fatal  strangu- 
lation. A  very  curious  case  is  related  by  Dr.  Dorsey, 
in  which  an  old  hernial  sac  formed  the  seat  of  stric- 
ture. A  small  process  of  sac,  which  had  been  reduced, 
and  was  almost  within  the  abdomen,  extended  through 


174  CONCEALED  HERNIA. 

the  upper  ring;  into  this  a  portion  of  the  ileum  had 
been  forced,  and  became  strangulated.  In  this  case  an 
operation  was  performed,  but  the  patient  died  a  few 
hours  afterwards;  and  on  a  post  mortem  examination, 
the  strangulated  intestine  was  found  mortified.* 

In  the  case  to  be  detailed  in  this  section,  which  I  saw 
m  consultation  with  my  departed  friend  Dr.  Perkin,  it 
would  really  appear,  from  his  account  of  the  dissection, 
as  if  the  strictured  bowel  had  been,  from  some  cause 
or  other,  deprived  of  its  contents,  whereby  its  internal 
surfaces  were  brought  into  contact,  and  the  promi- 
nence of  the  tumour  thus  destroyed.  There  is  an  ob- 
scurity about  this  case,  which  I  cannot  comprehend, 
and  which  I  must  leave  the  reader  to  explain  for  him- 
self. There  can  be  no  doubt  that  the  patient  died  with 
the  symptoms  of  strangulated  hernia. 


CASE  XXXI. 

Concealed  Hernia — Strictured  Bowel  Flaccid — Died, 

9th  mo.  1818.  I  was  lately  called  in  consultation  with 
Dr.  Perkin,  to  visit  J.  E.,  a  middle-aged  man,  corder  at 
Race  street  wharf.  I  was  informed,  that  four  days  pre- 
vious to  my  visit,  he  had  been  seized  with  constipation 
of  the  bowels,  pain,  and  vomiting.  All  efforts  to  relieve 
him  had  utterly  failed.  My  first  question  was,  has  he 
been  afflicted  with  rupture?  The  Doctor  said  he  had 
examined  the  groins,  but  could  discover  nothing — 
though  the  patient  had  been  the  subject  of  hernia. 

*  Dorsey's  Surgery,  vol.  ii.  p.  49. 


CONCEALED  HERNIA. 


175 


I  now  made  a  very  careful  examination,  and  could 
find  no  tumour.  The  patient  himself  believed  that  his 
rupture  had  no  concern  in  his  symptoms. 

We  met  again  in  a  few  hours:  and  found  that  the 
patient  had  been  sinking  rapidly.  At  our  next  visit,  a 
few  hours  after,  he  had  a  cold,  clammy  sweat,  with  a 
feeble  pulse;  tense  and  tumid  abdomen;  an  absence  of 
pain.  His  stomach  now  retained  every  thing  that  was 
given. 

I  again  examined  for  hernia,  being  convinced  that 
the  symptoms  strongly  indicated  it;  but  I  was  satisfied 
that  nothing  had  passed  the  abdominal  ring.  I  then 
remarked  to  Dr.  Perkin,  that  perhaps  strangulation 
might  exist  at  the  internal  ring;  but  as  there  was  no 
tumefaction  to  guide  us  to  the  part,  we  did  not  consider 
it  justifiable  to  cut  down  into  the  abdomen,  merely  upon 
conjecture.  A  few  hours  after  this  visit,  the  poor  man 
died. 

Dissection. 

Dr.  Perkin  dissected  the  body,  and  informed  me,  that 
he  found  a  hernial  sac  below  the  ring,  but  it  did  not 
descend  low  in  the  scrotum.  About  five  inches  of  in- 
testine was  found  in  the  sac  in  a  state  of  strangulation; 
it  was  of  a  very  dark  colour,  but  not  actually  morti- 
fied. The  bowels  above  the  stricture  were  enormously 
distended  with  flatus,  but  the  portion  within  the  sac 
was  flaccid,  and  its  sides  were  in  contact. 


176  CONCEALED  HERNIA. 


CASE  XXXII. 

Strangulated  Inguinal  Hernia — Apparent  deduction  by 

Taxis — Death. 

9th  mo.  20th,  1818.  A  poor  woman  was  brought  into 
the  Hospital  in  the  evening,  labouring  under  the  symp- 
toms of  strangulated  hernia.  The  hernia  was  inguinal, 
in  the  left  side,  and  had  been  strangulated  for  two 
days.  The  tumour  was  not  large;  the  abdomen  rather 
tumid  and  tender  on  pressure;  tongue  nearly  natural; 
pulse  pretty  good.  She  had  been  attended  previous  to 
her  admission  by  a  very  respectable  physician,  who, 
from  her  account,  had  made  various  efforts  to  reduce 
the  parts.  Among  other  plans,  a  tobacco  enema  had 
been  used,  which  made  her  very  sick,  and  procured 
some  evacuation. 

I  directed  two  grains  of  opium,  and  had  preparations 
made  for  an  operation.  Drs.  Hartshorne  and  Dorsey 
met  me  in  about  two  hours.  On  inquiry,  it  was  found 
that  a  portion  of  the  rupture  generally  remained  in  the 
sac,  and  the  patient  thought  that  a  part  had  been  re- 
duced by  her  physician  out  of  the  house. 

Dr.  Klapp,  who  had  attended  her,  was  sent  for,  but 
was  not  at  home.  As  it  was  late  in  the  evening,  and 
the  symptoms  were  not  so  urgent  as  in  many  cases, 
my  colleagues  proposed  delaying  the  operation  until 
morning.  It  was  agreed  to  put  the  patient  in  a  warm 
bath,  and  to  apply  gradual  pressure  by  a  succession  of 
smoothing  irons,  allowed  to  remain  on  the  part,  and 
changed  as  fast  as  they  became  warm. 


CONCEALED  HERNIA.  177 

Next  morning,  2l6t.  We  found  that  the  tumour  had 
disappeared.  It  had  been  reduced  by  Dr.  B.  H.  Coates, 
the  house  surgeon,  early  in  the  morning.  Dr.  C.  has 
kindly  assisted  me  in  making  out  a  report  of  the  case, 
and  states  his  recollections  on  this  point,  in  the  follow- 
ing terms: 

"  The  smoothing  irons  were  continued  on  the  part 
all  night,  as  the  woman  informed  me;  and  at  my  visit 
next  morning,  which  must  have  been  about  7  o'clock,  I 
found  to  my  extreme  gratification,  though,  as  it  subse- 
quently proved,  in  vain,  that  I  could  apparently  reduce 
the  tumour.  It  passed  up,  along  the  abdominal  canal, 
without  any  resistance;  and  I  observed  an  absence  of 
the  usual  rounded  form  and  elastic  resiliency  of  intesti- 
nal hernias;  and,  finally,  that  it  appeared  not  completely 
to  enter  the  abdomen,  a  slight  fulness  remaining  at  the 
upper  part  of  the  abdominal  canal,  extending  down- 
wards from  the  region  of  the  internal  ring.  From  these 
circumstances  I  inferred  the  tumour  to  be  omental;  and 
judged  that  there  remained  no  stricture." 

22d.  Found  the  patient  labouring  under  the  symp- 
toms of  strangulated  hernia,  and  evidently  sinking.  On 
examining  the  groin,  the  rupture  appeared  to  be  re- 
duced. I  desired  one  of  the  house  pupils  to  call  on  one  or 
both  of  my  colleagues,  and  request  them  to  see  the  case, 
and  if  they  believed  that  any  thing  could  be  done  for 
the  relief  of  the  patient,  to  call  a  consultation. 

She  was  seen  by  Dr.  Hartshorne,  who  agreed  with 
me,  that  nothing  further  could  be  done.  The  poor  wo- 
man died  early  on  the  morning  of  the  24th. 

A  post  mortem  examination  was  made  by  Dr.Coates. 
I  was  not  present,  but  have  received  from  Dr.  C.  the 
followhig  account  of  the  dissection. 

23 


178  CONCEALED  HERNIA. 

"A  crucial  incision  was  made.  As  I  raised  that  angle 
of  the  abdominal  parietes  which  contained  the  part 
affected,  I  saw  the  fold  of  intestine  falling  out  of  the 
internal  ring,  by  its  own  weight  and  continuity,  not- 
withstanding I  made  a  sudden  effort  to  prevent  it. 

"  It  was  thus  evident  that  there  was  no  strangulation 
at  the  time.  There  was  an  indentation  round  the  fold 
of  intestine,  which  embraced  its  whole  width.  I  after- 
wards applied  a  thong  of  buckskin  leather  loosely 
around  the  place  of  constriction,  in  such  a  manner  as 
to  maintain  the  original  form  of  the  intestine,  and  pre- 
served the  fold,  distended  and  thus  secured,  in  spirits, 
together  with  the  separated  sac.  I  have  seen  this  pre- 
paration within  the  last  two  or  three  years,  although  I 
have  either  lost  it  in  removing,  or  given  it  away. 

"  I  remember  examining  the  patient  very  carefully 
for  peritoneal  inflammation.  The  peritoneal  surface 
was  perfectly  healthy.  There  was  no  adhesion  or  effu- 
sion of  any  kind,  either  in  the  cavity  of  the  abdomen, 
or  in  the  sac;  nor  the  least  coagulating  lymph  adher- 
ing to  the  included  fold,  to  the  stricture,  or  to  the  lining 
of  the  sac.  The  intestine  was  not  reddened,  except  a 
little  irregular,  dark,  mottled  appearance,  which  I  took 
to  be  settling  of  blood.  There  was  not  any  large  col- 
lection of  feces  above  the  point  included  in  the  stric- 
ture; so  that  I  gained  the  impression  that  the  passage 
of  the  contents  of  the  intestine  was  not  obstructed." 


These  two  cases  made  a  very  strong  impression  on 
my  mind,  and  induced  me  to  believe  that  an  incarce- 
rated bowel  might  escape  detection,  unless  the  examina- 
tion was  very  carefully  conducted.  In  the  case  of  J.  E.,  Dr. 
Perkin  and  myself  both  examined  with  more  than  ordi- 


CONCEALED  HERNIA.  179 

nary  care,  and  could  discover  nothing.  And  in  the  case 
of  the  woman  at  the  Hospital,  knowing  that  there  had 
been  a  tumour,  and  finding  it  had  disappeared,  it  was 
a  fair  inference  that  the  hernia  was  reduced.  The  re- 
sult of  these  cases  were  to  me  a  source  of  great  unea- 
siness; and  I  determined,  if  another  obscure  case  pre- 
sented itself,  to  watch  it  very  narrowly. 

Not  a  great  while  after  this,  such  an  opportunity  was 
afforded;  and  I  attribute  the  successful  issue  of  the  case, 
in  a  great  measure,  to  my  previous  experience. 


CASE  XXXIII. 

Strangulated  Inguinal  Hernia — Stricture  at  Internal 
ring — Small  tumour  externally — Strangulated  eight 
days — Recovered. 

In  the  early  part  of  the  summer  of  1819,  my  friend 
Dr.  E.  A.  Atlee  sent  one  of  his  students  to  me  to  bor- 
row a  syringe.  The  student  stated  that  he  wished  to 
give  an  injection  to  a  patient  whose  bowels  M^ere  ob- 
stinately constipated.  From  his  account  I  was  im- 
pressed with  an  idea,  that  it  was  a  case  of  hernia,  and 
requested  him  to  state  to  Dr.  Atlee  my  apprehen- 
sions, and  to  desire  him  to  make  an  examination  of 
the  groins.  The  student  delivered  my  message,  and  not 
long  afterward,  I  received  the  following  history  of  the 
case  from  Dr.  Atlee.  On  the  30th  of  5th  mo.  the  patient 
was  attacked  with  symptoms  of  severe  colic.  The  usual 
remedies  were  resorted  to  without  affording  relief.  On 
the  31st  the  Doctor  suspected  hernia,  asked  the  patient 


180  CONCEALED  HERNIA. 

if  there  was  any  swelling  in  the  groin,  and  was  an- 
swered in  the  negative. 

The  constipation  was  obstinate,  the  stomach  rejected 
almost  every  thing,  and  he  complained  of  acute  pain 
over  the  abdomen,  with  tenderness  on  pressure. 

Bhsters  were  applied  to  the  abdomen,  wrists,  and 
ankles,  and  cathartics  and  enemata  were  freely  given, 
without  procuring  stools.    These  symptoms  continued 
until  6th  mo.  6th, — eight  days  from  the  commencement 
of  the  attack, — when  the  true  state  of  the  case  was  dis- 
oovered.  On  the  receipt  of  my  message.  Dr.  A.  made  a 
minute  examination  of  the  groins,  and  thought  he  dis- 
covered something  suspicious.  The  prominence  was  so 
slight  that  it  could  not  be  detected  by  the  eye,  and 
what  is  remarkable,  it  had  eluded  observation,  though 
the  patient  was  examined  while  naked,  and  lying  in  a 
warm  bath.  The  Doctor  now  thought  he  could  discover 
a  small  tumour  above  the  external  abdominal  ring.  At 
this  stage  of  the  case  I  was  requested  to  see  the  patient 
in  consultation.    On  a  minute  examination  1  could  feel 
a  small  tumour  at  the  internal  ring.     Dr.  Hewson  was 
sent  for,  and  met  us  very  soon.     On  examination  he 
could  feel  a  tumour,  and  agreed  with  us,  that  the  ope- 
ration should  be  immediately  performed.    I  made  an 
incision  directly  over  the  tumour,  and   exposed   the 
tendon  of  the  external  oblique  muscle.    This  was  di- 
vided by  the  director  and  bistoury,  until  the  hernial 
sac  was  brought  into  view;    this  was  opened,  and 
a  portion   of  intestine  was   discovered,   of  a  very 
dark  colour,  but  not  mortified.    The  stricture  was  not 
very  firm,  or  I  presume  mortification  would  have  oc- 
curred much  sooner.     I  divided  the  stricture  and  re- 
turned the  bowel.    The  sides  of  the  wound  were  now 


CONCEALED  HERNIA.  181 

approximated  by  the  interrupted  suture,  and  secured  by 
adhesive  strips,  and  the  dressing  completed  by  a  com- 
press and  bandage. — 12,  P.  M.  Pulse  85  in  the  minute, 
full  and  tense;  considerable  heat  in  the  head,  throbbing 
of  temporal  artery,  and  delirium.  Blood  was  taken  from 
the  arm,  which  afforded  immediate  relief. 

7th.  Noon.  Pulse  75;  is  easy,  and  inclinded  to  sleep; 
thirst  abated.  Complains  of  occasional  jumping  pain  in 
the  wound.  Affection  of  the  head  entirely  ceased. — 
Evening.  Has  taken  about  oiv.  of  ol.  ricini;  bowels  not 
yet  opened;  stomach  settled;  abdomen  not  distended 
or  painful;  pulse  80.  Had  an  injection  late  in  the  even- 
ing. 

8th.  Morning,  Pulse  about  80;  has  had  no  evacua- 
tion since  injection. — Evening.  Has  had  two  or  three 
plentiful  evacuations  of  fecal  matter;  somewhat  deli- 
rious; pulse  full  and  strong,  82  in  the  minute;  abdomen 
flaccid. 

9th.  Passed  a  restless  night,  with  considerable  deli- 
rium. Took  3j.  of  Glauber  salts,  with  an  opiate  during 
the  night.  This  morning  another  dose  of  salts  was  given 
which  produced  two  free  evacuations.  The  head  was 
shaved,  and  cold  water  repeatedly  applied;  the  body 
was  sponged  with  cold  water.  Rennet  whey  was  pre- 
scribed for  drink.  Another  ounce  of  salts  was  given  at 
noon. — Evening.  Has  had  three  small  evacuations;  the 
abdomen  is  free  from  pain.  Has  had  throbbing  of  the 
carotids,  with  some  aberration  of  mind  through  the 
day.  Another  dose  of  salts  was  prescribed.  A  wine- 
glassful  of  a  strong  infusion  of  hops  was  prescribed 
every  two  hours.  11,  P.  M.  Patient  somewhat  coma- 
tose, with  throbbing  of  the  carotids.  Apply  ice  to  the 
head. 


182  CONCEALED  HERNIA. 

10th.  Morning.  Has  had  a  recurrence  of  the  affection 
of  the  head.  Cups  were  apphed,  and  afforded  relief. 
Patient  is  now  pretty  free  from  dehrium,  and  is  inchned 
to  doze.  Tongue  is  heavily  loaded. — 10,  P.  M.  Pulse 
was  bounding,  about  75.  Has  had  a  bihous  evacuation, 
and  is  free  from  delirium. 

11th.  Morning.  Patient  considerably  improved;  pulse 
nearly  natural;  bowels  opened  several  times  during  the 
day. 

12th,  Has  had  a  good  night.  The  wound  has  a 
healthy  appearance,  except  a  slough  in  the  centre. 

From  this  time  the  patient  rapidly  recovered. 


CASE  XXXIV. 


Strangulated  Scrotal  Hernia — Apparent  Reduction — Re- 
covered. 

nth  mo.  25th,  1821.  I  was  called  this  day  in  con- 
sultation with  Dr.  Knight,  to  visit  J.  S.,  a  young  man 
about  twenty-eight  or  thirty  years  of  age.  He  had  lately 
recovered  from  a  three  months  illness  on  the  river  Sus- 
quehanna, with  the  epidemic  autumnal  fever.  He  has 
been  afflicted  with  hernia  for  many  years;  it  has  been 
several  times  strangulated,  but  he  has  always  been  able 
to  reduce  it. 

The  present  attack  commenced  on  the  evening  of 
the  23d  instant.  When  Dr.  Knight  was  called,  he  found 
a  strangulated  scrotal  hernia  of  considerable  size  on 
the  right  side.  The  patient  was  in  great  pain.  He  tried 
the  taxis,  bled  him,  and  gave  him  a  dose  of  opium.  On 


CONCEALED  HERNIA.  183 

the  succeeding  day  he  directed  a  cathartic,  ice  to  the 
tumour,  &c.  The  result  was  that  the  hernia  appeared 
to  be  reduced,  and  the  Doctor  anticipated  no  danger. 
The  patient  stated  that  there  was  always  more  fulness 
on  that  side  than  on  the  other.  The  Doctor  was  pre- 
vented by  a  case  of  midwifery,  from  seeing  him  again 
until  morning;  when  he  was  alarmed  at  finding  the  pa- 
tient's bowels  still  constipated,  and  that  he  had  sterco- 
raceous  vomiting  and  singultus.  In  consequence  of  this 
state  of  things  my  attendance  in  consultation  was  de- 
sired. 

On  examination  I  readily  distinguished  the  spermatic 
cord.  There  was  rather  a  preternatural  fulness  in  the 
course  of  the  abdominal  ring,  and  some  tenderness  on 
pressure,  particularly  about  the  internal  ring.  But  as 
the  statement  of  the  patient  showed  that  there  was  al- 
ways some  fulness  of  this  part,  the  surgeon  might  easily 
have  been  deceived  into  the  belief  that  the  hernia  had 
been  reduced,  had  it  not  been  for  the  presence  of 
marked  evidences  of  strangulation.  We  recommended 
the  immediate  removal  of  the  patient  to  the  Hospital. 
He  requested  two  hours  to  consider  of  it.  At  the  con- 
clusion of  that  time,  three  grains  of  opium  were  given, 
and  he  was  removed  in  a  carriage.  Just  before  the 
operation,  thirty  drops  of  laudanum  were  exhibited,  and 
I  proceeded,  Drs.  Hartshorne  and  Price  being  present 
in  consultation. 

I  made  a  free  incision  through  the  integuments,  be- 
ginning above  the  internal  ring  and  extending  down  on 
the  scrotum.  I  dissected  down  until  the  tendon  of  the 
external  oblique  muscle  was  exposed.  In  doing  this, 
an  artery  had  to  be  secured.  Aided  by  the  director  and 
bistoury,  I  now  divided  the  parts,  from  above  down- 


184  CONCEALED  HERNIA. 

ward,  and  soon  laid  bare  a  hernial  sac,  distended  with 
a  Httle  fluid.  I  opened  it  in  the  usual  manner,  and 
exposed  the  testicle.  The  hernia  was  congenital.  We  now 
discovered  a  piece  of  intestine  just  peeping  at  the  mouth 
of  the  external  ring.  Its  colour  was  good.  I  divided  the 
parts  slightly,  and  could  pass  my  finger  freely  round  the 
bowel,  but  found  that  it  would  not  return.  I  now  pushed 
my  finger  along  the  course  of  the  canal  till  I  came  to 
the  internal  ring;  there  I  distinctly  felt  the  stricture, 
and  divided  it  directly  upward  with  Cooper's  blunt  bis- 
toury, (my  own  not  being  at  hand,)  and  reduced  the 
intestine  with  great  ease.  We  then  brought  the  lips  of 
the  wound  together  with  adhesive  plaster,  and  two 
stitches  on  the  scrotum,  and  the  patient  was  put  to  bed. 
We  directed  his  knees  to  be  bent  and  supported;  gave 
him  a  little  wine  and  water;  and  ordered  him  thirty 
drops  of  laudanum  every  six  hours,  and  barley-water 
for  nourishment. 

26th.  The  patient  has  passed  a  good  night.  The  sin- 
gultus and  vomiting  have  ceased.  He  appears  now 
quite  comfortable,  but  he  has  complained  of  great  thirst 
through  the  night.  His  abdomen  is  very  tumid,  and 
tympanitic;  his  pulse  112;  and  his  tongue  furred.  Or- 
dered castor  oil,  a  table-spoonful  every  two  hours. — 
Evening.  The  oil  has  not  operated,  but  the  patient  has 
passed  flatus.  Directed  the  oil  to  be  continued.  The 
abdomen  is  still  very  tympanitic,  though  somewhat 
less  tumid. 

27th.  The  patient  has  had  free  evacuations  from  his 
bowels  after  having  taken  eight  doses  of  the  oil.  He  is 
evidently  better;  has  less  thirst;  stomach  settled;  no 
singultus;  his  tongue  is  still  furred,  and  rather  dark.  The 
tympanitis  has  subsided.    Pulse  90  in  the  morning;  96 


CONCEALED  HERNIA.  185 

in  the  evening.  Directed  to  continue  tlie  barley-water; 
to  use  molasses  and  water,  or  plain  water  for  drink;  and 
if  restless,  an  opiate. 

28th.  The  patient  is  evidently  improving.  He  has 
had  an  evacuation  from  his  bowels,  and  the  tympanitis 
has  subsided.  Pulse  84;  tongue  still  furred  and  rather 
dark.  Directed  a  diet  of  rye  mush  and  molasses,  or 
oatmeal  gruel. 

29th.  Morning.  The  patient  is  still  improving.  His 
tongue  is  disposed  to  become  clean.  Directed  ol.  ricini 
5SS.  every  two  hours  until  the  bowels  are  moved. — Even- 
ing. Three  doses  of  the  oil  have  produced  two  stools,  and 
the  tongue  is  becoming  clean.  Pulse  84.  The  patient  is 
in  fine  spirits. 

This  patient  recovered  and  was  discharged  cured. 


24 


CHAPTER  Vlll. 


UMBILICAL  HERNIA. 


My  experience  in  strangulated  umbilical  hernia  may 
be  considered  as  limited.  I  have,  however,  witnessed 
a  few  cases  which  may  be  worthy  of  record. 

A  very  interesting  case  of  this  form  of  the  disease 
came  under  my  notice  in  consultation  with  Drs.  Dorsey 
and  Cathrall,  while  I  was  surgeon  to  the  Almshouse 
hospital.  The  strangulation  of  the  bowel  was  caused 
by  a  number  of  bands  passing  across  the  umbilical  open- 
ing in  various  directions.  These  occasioned  considera- 
ble difficulty  in  the  operation — the  patient  died.  Dr. 
Dorsey  performed  the  operation,  and  thus  notices  the 
case  in  his  work  on  surgery: 

"  In  one  case  of  umbilical  hernia,  I  was  greatly  em- . 
barrassed  by  finding  the  intestine  strangulated  in  seve- 
ral different  places  by  bands  passing  from  the  omentum 
to  the  intestine.  These  bands,  which  were  elongated 
adhesions  of  a  very  firm  texture,  converted  the  hernial 
sac  into  a  cavity  resembling  the  ventricles  of  the  heart; 
the  morbid  productions  extending,  like  the  chorda?  ten- 
dineae,  from  one  part  of  the  cavity  to  another;  under 
several  of  these  cords,  portions  of  the  ileum  had  been 
strangulated,  and  by  cautious  dissection,  I  succeeded  in 
liberating,  and  returning  into  the  abdomen,  the  recently 
protruded  parts." 


UMBILICAL  HERNIA.  187 

A  case  of  umbilical  rupture  of  a  peculiar  character 
came  under  my  care  in  the  spring  of  1817,  which  I  will 
relate  from  my  notes. 


CASE  XXXV. 

Umbilical  Hernia — Mortification  of  the  Integuments — 

Death. 

3d  mo.  8th,  1817.  Dr.  Hollingshead,  of  Moorestown, 
New  Jersey,  came  over  to  see  me,  and  requested  my 
immediate  attendance  on  one  of  his  patients  in  Eves- 
ham. We  crossed  the  Delaware  with  considerable  dif- 
ficulty on  account  of  the  ice,  and  arrived  at  the  house 
just  before  night. 

The  patient  was  a  farmer's  wife,  of  middle  age,  sub- 
ject to  umbilical  hernia  for  about  twenty  years,  but  was 
always  able  to  reduce  it  until  the  morning  of  the  5th 
instant,  when  it  became  strangulated.  I  found  the  in- 
teguments covering  the  tumour  perfectly  livid,  and  in 
a  state  of  mortification;  this  foreclosed  all  reasonable 
prospect  of  success  from  an  operation. 

At  the  request  of  the  Doctor  I  communicated  to  the 
patient  a  candid  statement  of  her  awful  situation.  The 
extremely  slender  prospect  of  success  from  an  opera- 
tion was  fairly  presented  to  her.  It  could  not,  there- 
fore, be  encouraged,  and  yet  if  desired,  this  last  effort 
should  not  be  refused.  As  she  appeared  to  have  con- 
siderable strength,  and  with  her  husband  decided  in 
favour  of  the  operation,  it  was  performed.  An  incision 
was  carefully  made  through  the  skin;  no  bleeding  fol- 


188  UMBILICAL  HERNIA. 

lowed,  and  the  part  appeared  as  entirely  insensible  to 
pain  as  a  piece  of  black  leather.  I  divided  the  stric- 
ture with  a  blunt-pointed  bistoury.  The  hernial  sac 
contained  a  portion  of  omentum  and  small  intestine  in 
a  state  of  complete  mortification. 

There  was  a  hardness  in  the  integuments  round  the 
margin  of  the  hernia  for  several  inches,  like  a  cake  of 
placenta,  caused  it  is  supposed  by  inflammation. 

The  adhesions  were  so  firm,  that  I  could  not  draw 
out  into  view  any  portion  of  living  bowel.  Little  else 
remained  after  liberating  the  parts,  than  to  rest  the 
case  upon  the  efforts  of  nature;  but  all  was  unavailing, 
she  died  on  the  morning  of  the  tenth  instant. 


I  once  attended  an  old  black  woman  in  Middle  alley, 
a  Dispensary  patient,  who  had  a  large  umbilical  rup- 
ture in  a  state  of  strangulation,  with  gangrene  of  the 
integuments.  In  this  case  no  operation  was  attempted, 
and  the  patient  died. 

A  most  extraordinary  case  of  this  disease  fell  under 
my  observation  some  years  ago,  in  company  with  my 
friend  Dr.  Hartshorne. 

The  patient  was  a  female  who  was  attended  by  the 
late  Dr.  Cleaver,  who  called  upon  us  to  assist  him  in 
the  operation;  the  hernia  was  small.  A  stricture  was 
divided,  and  a  portion  of  bowel  returned.  The  case 
went  on  very  favourably  for  several  days,  when  most 
unexpectedly  the  patient  was  attacked  with  tetanus, 
and  soon  died. 

I  have  not  ascertained  that  Dr.  C.  left  any  note  of 
the  case,  but  so  far  as  my  recollection  of  the  circum- 
stances may  be  relied  on,  the  facts  were  these.  On  ex- 
amination after  death,  a  small  portion  of  intestine  was 


UMBILICAL  HERNIA.  189 

found  in  a  mortified  state,  without  the  usual  evidences  of 
adhesion  from  previous  inflammation.  The  impression 
left  on  my  mind  is,  that  owing  to  some  peculiar  con- 
dition of  the  constitution  of  this  patient,  the  usual  order 
of  nature  was  interrupted,  and  the  dead  bowel  instead 
of  producing  surrounding  inflammation,  had  acted  as 
an  irritant  to  the  nervous  system,  causing  tetanic 
spasm,  and  death. 

Dr.  Hartshorne  informs  me,  that  he  has  a  distinct 
recollection  of  the  case,  and  of  its  termination  in  teta- 
nus, and  states,  that  he  once  operated  on  a  woman  at 
the  Pennsylvania  Hospital,  for  strangulated  umbilical 
hernia,  who  was  strongly  threatened  with  tetanus,  but 
who  finally  recovered. 

The  occurrence  of  umbilical  rupture  in  early  infancy 
is  not  uncommon,  but  I  believe  it  will  be  found  that  in 
a  large  proportion  of  these  cases,  nature  performs  a 
radical  cure,  and  thus  renders  it  unnecessary  for  the  sur- 
geon to  interfere.  This  opinion  is  confirmed  by  the  ex- 
perience of  Dr.  Physick.  In  a  late  conversation  with 
him,  he  stated  to  my  son,  that  in  the  whole  course  of 
his  practice,  he  had  seldom  experienced  any  trouble  in 
the  treatment  of  these  cases,  and  had  never  considered 
it  necessary  to  perform  any  operation  for  their  cure.  It 
is  only  requisite  in  ordinary  cases,  to  direct  the  mother 
or  nurse  to  place  the  hand  over  the  tumour,  when  the 
child  cries,  and  to  keep  the  bowels  open.  If  these  direc- 
tions are  not  eflfectual  in  retaining  the  bowel,  the  appli- 
cation of  a  graduated  compress,  secured  by  strips  of 
sticking  plaster,  will  be  found  useful. 

Dessault  has  recommended  a  plan  for  the  radical 
cure  of  umbilical  hernia,  which  he  has  frequently  per- 
formed, and  considers  quite  safe.     I  pursued  this  plan 


190  UMBILICAL  HERNIA. 

many  years  ago,  in  a  case  in  which  I  was  concerned 
with  Drs.  Wistar  and  Physick.  The  case  resulted  fa- 
vourably, though  not  without  considerable  anxiety  on 
our  part.  It  is  detailed  in  this  place,  not  with  a  view  of 
recommending  the  operation,  but  to  show  that  it  is  not, 
in  every  instance,  so  trifling  an  affair  as  one  might  be 
led  to  conclude. 

With  my  present  experience,  I  would  not  repeat  the 
operation  in  a  similar  case,  but  would  prefer  relying  on 
the  efforts  of  nature,  with  an  observance  of  the  direc- 
tions just  noticed. 


CASE  XXXVI. 

Umbilical  Hernia — Radical  Cure. 

lOth  mo.  31st,  1810.  S.  A.,  aged  about  twenty-two 
months,  has  had  an  umbilical  hernia  from  his  birth. 
This  day,  in  consultation  with  Drs.  Wistar  and  Phy- 
sick, I  commenced  an  attempt  to  produce  a  radical  cure 
according  to  the  plan  of  Dessault.  Dr.  Wistar  took  the 
tumour  between  his  fingers,  having  first  returned  the 
contents  of  the  sac.  I  now  passed  a  ligature  three  times 
round  the  base  of  the  integuments  and  the  sac,  and 
secured  it  at  each  turn  by  a  double  knot.  The  ligature 
was  only  drawn  tight  enough  to  give  an  inconsiderable 
degree  of  pain;  the  child  did  not  cry. 

11th  mo.  1st.  The  child  has  not  appeared  to  sustain 
any  inconvenience.  His  bowels  are  rather  lax.  He  is 
kept  on  a  soft  vegetable  diet,  especially  rye  mush.  The 
tumour   looks  a   little   faded   in   colour,   and    rather 


UMBILICAL  HERNIA.  191 

slirunkeii.  It  now  appears  as  if  the  parts  were  disposed 
to  form  another  sac  behind  the  one  which  has  been 
inclosed  in  the  hgature;  but  as  pressure  on  this  pro- 
truded part  does  not  cause  it  to  return,  there  is  reason 
to  beheve  that  it  is  occasioned  by  the  cellular  mem- 
brane beins  a  little  inflamed  and  thickened. 

2d.  The  patient  is  still  free  from  pain  and  uneasiness. 
On  inquiry,  it  appears  that  he  rubbed  off  the  ligature 
this  morning:  an  inflamed  ring  marks  the  place  where 
it  was  applied,  and  the  integuments  containing  the  sac 
are  certainly  a  little  thickened.  While  fixing  him  for 
the  purpose  of  applying  the  ligature  again,  he  became 
restless  and  cried;  but  it  really  appears  as  if  the  pro- 
trusion of  the  bow  el  is  not  so  great  as  before  the  first 
application. 

The  integuments  were  now  taken  hold  of  by  Dr. 
Wistar,  as  before,  and  I  passed  the  ligature  rather  be- 
low the  place  where  the  previous  one  had  been  applied, 
and  secured  it  by  three  turns,  with  a  double  knot  on 
each  turn,  drawing  it  considerably  tighter  than  before. 
This  ligature  gave  rather  more  pain  than  the  first,  but 
not  a  great  deal. 

3d.  The  ligature  retains  its  situation  very  well.  The 
lower  part  of  the  tumour  appears  of  a  purplish  hue. 
The  tumour  itself  is  rather  tense.  The  patient  does 
not  appear  to  sustain  any  material  inconvenience;  he 
plays  about,  and  is  very  lively. 

4th.  The  tumour  seemed  a  little  shrunken,  and  it  was 
concluded  to  pass  a  ligature  sufficiently  tight  to  inter- 
cept the  circulation.  This  was  accordingly  done,  with- 
out removing  the  other  ligature.  It  gave  considerable 
momentary  pain,  but  it  appeared  soon  over. 

5th.  The  tumour  looks  black.     A  vesication  filled 


192  UMBILICAL  HEIINIA. 

with  bloody-coloured  serum  has  been  formed  near  its 
base. 

8th.  The  ligature  retains  its  situation.  The  vesicated 
part  has  dried  completely,  and  the  whole  surface 
of  the  tumour  is  of  a  light-purplish  colour.  It  appears 
to  be  rather  hard.  On  puncturing  it  with  a  lancet,  it 
did  not  bleed,  but  the  tumour  has  not  shrunk. 

11th.  The  exterior  covering  of  the  tumour  appears 
to  have  sloughed  away,  leaving  a  living  surface  beneath, 
from  which  some  pus  escapes;  and  pus  is  also  formed 
about  the  ligature.  Some  slight  inflammation  is  appa- 
rent in  the  skin  near  the  tumour;  for  this  I  directed 
a  poultice  containing  some  lead-water.* 

15th.  Morning.  The  poultice  has  been  continued  un- 
til this  day.  The  ligature  has  gradually  cut  through 
the  greater  part  of  the  integuments,  leaving  the  sac 
nearly  bare,  and  a  considerable  cavity  in  the  integu- 
ments. This  has  not  a  pleasant  appearance.  I  now  passed 
the  last  ligature  round  the  tumour,  and  drew  it  quite 
tight.  On  visiting  him  in  the  afterrioon,  for  the  purpose 
of  applying  adhesive  strips,  so  as  to  give  as  much  sup- 
port as  possible  to  the  parts,  I  found  that  the  integu- 
ments had  gradually  contracted  since  the  poultice  had 
been  removed,  and  I  believe  that  the  poultice  was  cer- 
tainly the  cause  of  the  parts  looking  so  relaxed,  and 
the  ulcer  so  large,  as  they  did  in  the  morning.  The 
child  still  enjoys  fine  health  and  spirits. 

*  About  the  time  of  the  application  of  the  poultice,  the  extent  of  the 
ulcerated  surface  caused  me  considerable  uneasiness;  had  the  child  been 
attacked  with  severe  cough,  or  long-continued  crying,  there  would,  I  be- 
lieve, have  been  some  risk  of  a  rupture  of  the  new-formed  parts,  and  con- 
sequent protrusion  of  the  bowels. 


UMBILICAL  HERNIA.  193 

16tli.  The  ligature  and  tumour  came  off  this  morn- 
ing, leaving  a  small  aperture  and  granulations  over  its 
surface.  A  piece  of  adhesive  plaster  was  applied  over 
the  part,  compresses  placed  on  it,  and  a  bandage  car- 
ried over  the  whole,  to  complete  the  dressing. 

Cicatrization  took  place  very  soon,  and  the  cure  has 
proved  complete. 


25 


CHAPTER  IX. 


STRANGULATION  WITHIN  THE  ABDOMEN. 

The  symptoms  which  mark  a  violent  attack  of  stran- 
gulated hernia  may  exist,  without  a  protrusion  at  any 
point.  The  obscurity  of  these  cases  baffles  all  efforts  at 
relief,  and  the  physician  is  obliged  to  look  on,  and  wit- 
ness a  fatal  termination. 

Several  cases  of  this  description  have  fallen  under 
my  observation;  in  two  of  these  a  post  mortem  examina- 
tion was  permitted,  and  the  cause  satisfactorily  ascer- 
tained. In  another  instance,  which  occurred  some  years 
ago,  the  event  was  equally  distressing,  though  the  cause 
of  the  symptoms  remains  a  mystery.  The  patient  was 
a  remarkably  fine-looking  young  man  from  Kentucky, 
tall,  yet  very  muscular  and  strong.  He  had  come  to  the 
city  to  purchase  a  stock  of  goods,  and  was  suddenly 
seized,  in  a  state  of  high  health,  with  the  symptoms  of 
strangulated  hernia.  Dr.  Physick  was  called  to  visit 
him,  suspected  hernia,  and  made  a  minute  examination, 
but  could  discover  no  protrusion. 

He  requested  me  to  see  the  patient  in  consulta- 
tion; the  examination  was  carefully  repeated  by  both 
of  us,  but  we  could  discover  nothing  to  justify  an  ope- 
ration. He  died  on  the  fifth  day  from  his  attack.  To 
our  great  regret  we  were  not  permitted  to  make  a  post 
mortem  examination;  though  from  the  symptoms  there 


STRANGULATION  WITHIN  THE  ABDOMEN.      195 

can  scarcely  be  a  doubt,  that  his  death  was  caused  by- 
some  mechanical  obstruction  in  the  bowels. 

In  the  two  cases  in  which  a  post  mortem  examina- 
tion took  place,  it  will  be  perceived,  that  the  accumu- 
lation of  flatus  in  the  bowels  had  the  principal  agency 
in  keeping  up  the  obstruction. 

This  fact  I  consider  important,  as  pointing  to  the 
only  method  of  treatment  which  seems  to  offer  any 
prospect  of  relief  under  such  circumstances. 

If  a  cord  of  omentum,  thrown  across  the  abdomen, 
be  pressed  by  the  distended  bowel  to  its  utmost  point  of 
tension,  it  is  evident  that,  as  the  accumulation  of  flatus 
increases,  the  sides  of  the  bowel  will  be  opposed  by  this 
tightened  cord,  and  its  internal  surfaces  be  brought  into 
contact.  The  greater  the  distension,  the  more  firmly 
will  the  bowel  be  secured,  and  the  more  complete  will 
be  the  obstruction.  The  only  way  in  which  parts  thus 
strangulated  can  be  relieved,  is  by  withdrawing  the 
flatus  from  the  bow  els,  and  thus  restoring  their  freedom 
of  motion.  In  another  case,  I  should  attempt  to  effect 
this  by  the  gum-elastic  tube,  and  exhausting  syringe, 
employed  as  recommended  in  the  remarks  which  follow 
case  xxxviii.,  at  the  close  of  this  chapter. 


CASE  XXXVII. 


Constipation — Obstruction  produced  by  Diseased  Omen- 
tum— Death, 

\st  mo.  3d,  1831.  M.  B.,  aged  about  forty-eight  years, 
a  large,  corpulent  woman,  the  mother  of  twelve  children, 


196  STRANGULATION 

was  suddenly  attacked  in  the  market,  on  the  morning 
of  the  1st  instant,  with  violent  abdominal  pain,  sickness 
of  stomach,  and  vomiting. 

Dr.  Beasley  saw  her  soon  after  the  attack.  She  in- 
formed him  that  her  bowels  had  been  constipated  for 
two  days,  and  that  she  had  taken  nothing  that  morning 
to  which  she  could  refer  the  attack;  her  breakfast  had 
been  light  and  simple.  The  Doctor  endeavoured  to 
allay  the  violent  pain  by  opiates,  and  administered 
calomel,  infus.  senna,  and  ol.  ricini,  to  act  upon  the 
bowels.  She  had  been  twice  bled,  and  was  placed  in  a 
warm  bath. 

On  the  evening  of  the  2d,  I  was  called  in  consulta- 
tion. All  attempts  to  act  upon  the  bowels  had  failed, 
though  the  stomach  was  more  settled.  From  the  history 
of  the  case  I  immediately  suspected  strangulated  her- 
nia, but  on  a  careful  examination  no  tumour  could  be 
discovered.  I  encouraged  Dr.  Beasely  to  persist  in  the 
use  of  castor  oil,  and  advised  anodyne  enemata  to  calm 
the  restlessness  of  the  patient.  There  was  at  this  time 
considerable  tenderness  on  pressure  over  the  abdomen, 
extending  around  the  umbilicus,  and  from  the  left,  to- 
ward the  right  side.  Her  pulse  was  feeble,  and  the  skin 
cool.  Before  daylight,  on  the  morning  of  the  3d,  she 
died. 

Dissection, 

Dr.  Beasley  made  a  post  mortem  examination,  at 
which  I  was  present.  A  portion  of  the  omentum  was 
formed  into  a  rope  or  cord,  which  extended  from  the 
left  to  the  right  side,  dipped  down  into  the  pelvis,  and 
was  firmly  attached  to  the  peritoneum  across  the  sym- 
physis pubis.     Involved  in  this  cord  we  found  the  left 


WITHIN  THE  ABDOMEN.  197 

ovarium  with  an  hydatid  attached  to  it.  The  bov/els 
were  monstrously  distended  with  flatus.  The  cord  of 
omentum  drawn  thus  firmly  across  the  abdomen,  acted 
hke  a  ligature  upon  the  distended  intestines,  and  the 
portions  which  came  wdthin  its  range,  were  pressed 
together,  thus  forming  a  complete  obstruction  in  the 
passage;  and  the  greater  the  distension,  the  firmer  was 
the  pressure  of  the  cord. 

We  suspected  that  this  state  of  things  must  have 
been  caused  by  a  previous  attack  of  peritoneal  inflam- 
mation, probably  depending  on  puerperal  lever.  On  in- 
quiry of  the  husband  we  ascertained,  that  a  few  days 
after  the  birth  of  one  of  her  children,  ten  years  ago, 
she  was  attacked  with  violent  fever,  and  pain  in  the 
abdomen,  which  confined  her  for  a  long  time.  Since 
this  time  she  had  been  subject  to  occasional  attacks 
of  disease  in  the  abdomen.  The  ovarium  contained  a 
considerable  quantity  of  hair  of  a  whitish  appearance. 


CASE  XXXVIII. 

Strangulated  Scrotal  Hernia — Stricture  divided — Ob- 
struction continued  from  adhesionswithin  the  abdomen^ 
and  distension  of  bowels. 

During  my  pupilage  with  Dr.  Wistar,  a  highly  inte- 
resting case  of  strangulated  hernia  occurred  in  his 
practice.     The  following  is  the  history  of  the  case: 

James ,  an  apprentice  to  J.  S.,  aged  about  six- 
teen years,  had  been  for  several  years  the  subject  of  a 


198  STRANGULATION 

scrotal  hernia.  As  he  was  able  to  return  the  bowel 
without  difficulty,  he  never  made  it  known  to  his  mas- 
ter, and  had  not  worn  a  truss.  On  the  evening  of  the 
3d  instant,  he  was  unable  to  return  the  bowel  as  usual, 
and  on  the  following  morning  Dr.  Griffitts  saw  him: 
he  directed  v.  s.,  warm  bath,  purgative  injections,  &c., 
and  endeavoured  to  reduce  the  tumour  by  taxis.  In  the 
evening  he  was  bled  again,  and  the  other  remedies  w-ere 
continued.  Several  days  elapsed,  during  which  time  Dr. 
Currie  was  called  in  consultation;  the  usual  means 
were  tried  without  effect;  and  on  the  evening  of  the 
9th,  Dr.  Wistar  was  called,  and  with  the  aid  of  Dr. 
Physick,  proceeded  to  the  operation  late  at  night. 

The  protruding  bowel,  together  with  a  portion  of 
omentum,  were  found  in  a  state  of  sphacelation.  The 
stricture  was  divided.  Two  orifices  were  formed  in  the 
intestine,  through  the  upper  of  which  a  flexible  tube 
was  passed,  and  several  injections  administered,  but 
with  little  effect;  for  although  the  patient  passed  a 
small  portion  of  feces  from  the  artificial  orifice  and  the 
rectum,  yet  the  vomiting  still  continued. 

The  patient  slept  about  an  hour  after  the  operation, 
and  passed  the  next  day  without  appearing  to  suffer 
much.  About  9  o'clock  in  the  evening  he  became  rest- 
less, and  vomited  several  times,  complained  of  violent 
pain,  which  commenced  about  the  umbilicus,  and  ex- 
tended across  towards  the  right  hypochondriac  region. 
Warm  fomentations  were  applied  to  the  abdomen,  and 
he  took  warm  mint-tea,  by  which  the  pain  and  vomit- 
ing were  relieved.  Two  injections  were  thrown  into 
the  artificial  anus,  a  poultice  was  applied  to  the  wound, 
and  the  patient  was  left  under  my  care  for  the  night. 


WITHIN  THE  ABDOMEN.  199 

He  was  exceedingly  restless  through  the  night,  and 
vomited  stercoraceous  matter  very  copiously.  Opium 
was  exhibited,  both  in  the  liquid  and  solid  form,  but  was 
immediately  rejected  by  the  stomach.  He  dozed  at 
short  intervals,  but  had  no  refreshing  sleep;  the  extre- 
mities were  cold,  and  his  strength  nearly  exhausted; 
warm  bricks  were  applied  to  the  feet.  In  the  morning 
he  was  slightly  relieved;  took,  in  the  course  of  the  day 
and  the  next  night,  wine-whey,  wine,  &c.  On  the  after- 
noon of  the  13th  he  became  delirious,  his  countenance 
exhibited  marks  of  extreme  prostration,  and  about  five 
o'clock  on  the  morning  of  the  14th,  he  died. 

Dissection. 

Having  obtained  permission  to  open  the  body,  (Dr. 
Wistar  being  absent,)  I  proceeded  to  the  examination 
under  the  direction  of  Drs.  Physick,  Griffitts,  and 
Currie.  Upon  opening  the  abdomen,  the  small  intestines 
were  found  amazingly  distended  with  flatus  and  feces; 
the  omentum  was  remarkably  free  from  adipose  sub- 
stance, and  was  closely  adhering  to  the  intestines  in 
the  vicinity  of  the  stricture.  The  ends  of  the  protruded 
portion  of  bowel  were  firmly  agglutinated  to  the  exter- 
nal wound,  and  the  intestines  above  the  stricture  were 
adherent  to  each  other,  and  in  a  state  nearly  approach- 
ing to  mortification.  The  part  which  had  been  strangu- 
lated, was  a  portion  of  the  ileum,  which  commenced 
about  twenty-seven  inches  from  its  termination  in  the 
ccecum.  The  intestine  leading  from  the  stricture  toward 
the  duodenum  was  very  much  distended,  except  a  por- 
tion which  was  attached  to  the  ring,  and  extended  in  an 
obhquc  direction  across  the  pelvis,  presenting  an  ap- 


200  .  STRANGULATION 

pearance,  which  was  aptly  compared  by  Dr.  Physick, 
to  one  of  the  ureters  entering  the  bladder. 

This  portion  being  fixed  to  the  strictured  part,  was 
pressed  upon  by  the  mass  of  distended  bowel  from 
above,  while  on  its  lower  surface  it  was  antagonized 
by  the  large  muscles  lining  the  pelvis,  and  thus  its  sides 
were  firmly  pressed  together,  and  the  calibre  of  the  in- 
testine obliterated,  for  the  distance  of  several  inches. 
The  bowels  above  being  distended  beyond  the  point  of 
reaction,  the  obstruction  was  maintained,  and  must 
have  continued  until  some  means  could  have  been 
adopted  to  induce  peristaltic  action,  and  thus  cause  an 
expulsion  of  their  contents. 

The  colon  and  rectum  were  empty,  and  very  much 
contracted;  the  stomach  contained  a  large  portion  of 
fluid,  and  dark  stercoraceous  matter. 

Remarks. 

In  looking  over  this  case  which  occurred  many  years 
ago,  some  views,  suggested  by  subsequent  experience, 
may  be  worthy  of  consideration  in  this  place. 

That  the  intestines  may  be  so  distended  with  flatus 
as  to  suspend  peristaltic  action,  is  proved  by  ample  ex- 
perience. Thus  in  the  latter  stage  of  some  of  our  fevers 
the  tympanitic  abdomen  occurs,  as  one  of  the  most 
alarming  symptoms.  I  have  known  this  state  of  things 
to  occur  during  the  existence  of  a  diarrhoea,  and  have 
observed  that  the  bowels  were  not  only  incapable  of 
discharging  flatus,  but  that  the  diarrhcea  was  entirely 
suspended. 

In  some  violent  cases  of  colic,  accompanied  with  con- 
stipation and  great  distension  of  the  bowels,  it  is  well 
known  that  active  medicines  administered  by  the  mouth. 


WITHIN  THE  ABDOMEN.  201 

and  enemata  thrown  into  the  rectum,  sometimes  fail  in 
producing  the  desired  effect,  and  rehef  is  finally  ob- 
tained by  the  introduction  of  a  flexible  tube  into  the 
colon,  through  which  flatus  is  extracted  by  an  exhaust- 
ing syringe. 

A  remarkable  instance  of  this  kind  occurred  to  me 
several  years  ago.  I  was  called  in  consultation  with  a 
young  practitioner,  in  a  case  of  extreme  danger,  at- 
tended with  obstinate  constipation  and  enormous  dis- 
tension of  the  belly.  A  variety  of  medicines  had  been 
tried  without  any  beneficial  effect.  I  explained  the 
views  here  presented,  to  the  physician  in  attendance; 
he  most  industriously  employed  the  means  suggested, 
and  while  engaged  in  the  operation  with  the  tube  and 
syringe,  the  bowels  began  to  act  for  themselves,  and 
flatus  and  feces  were  expelled  in  abundance,  to  the 
great  relief  of  the  patient,  who  finally  recovered. 


26 


CHAPTER  X. 


ANOMALOUS  CASES. 


The  following  cases  do  not  fall  under  any  of  the 
general  heads  of  the  subject  of  hernia,  but  as  they  are 
not  without  some  interest,  I  have  placed  them  together 
in  this  chapter,  which  may  be  considered  as  a  kind  of 
appendix  to  those  already  given. 


CASE  XXXIX. 

Hernia — Sudden  Death  from  Strangulation, 

2d  mo.,  1 822.  Anthony,  an  old  Italian  sailor  at  the 
Hospital,  who  was  just  recovering  from  a  severe  con- 
tusion of  the  spine,  was  attacked  with  strangulated  her- 
nia. I  was  passing  through  the  ward  about  half  an  hour 
after  it  occurred,  and  was  told  by  one  of  the  patients 
that  Anthony  had  the  colic.  I  inquired  if  he  had  rup- 
ture, and  ascertained  the  fact.  It  was  an  enormously 
large  hernia,  and  from  that  circumstance  I  expected  it 
would  be  more  readily  reduced.  I  directed  the  house- 
surgeon  to  try  some  of  the  milder  plans  of  reduction, 
as  the  old  man  was  feeble;  and  intended  next  day,  if 
he  was  not  relieved,  to  have  a  consultation;  but  to  my 
surprise,  on  visiting  the  house  next  morning,  I  was  in- 


ANOMALOUS  CASES.  203 

formed  that  poor  old  Anthony  died  at  about  G  o'clock, 
A.  M.  The  time  that  elapsed  between  the  attack  and 
the  death  of  the  patient  was  about  twelve  hours:  a  very 
uncommon  result,  especially  in  large  ruptures. 

The  treatment  that  had  been  employed  for  the  pur- 
pose of  effecting  the  reduction,  was  one  moderate  bleed- 
ing, small  doses  of  jalap  and  cream  of  tartar,  and  the 
taxis. 

No  post  mortem  examination  was  permitted  by  his 

friends. 


CASE  XL. 

Entero-Epiplocele — Gradual  approach  of  Strangulation^ 

Double  Sac — Death. 

10th  mo.  19th,  1818.  An  old  soldier  was  admitted  into 
the  Almshouse  hospital  last  evening.  I  saw  him  this 
morning,  and  received  the  following  account. 

He  had  been  afflicted  with  hernia  since  the  year  1793, 
when  he  was  a  soldier  in  St.  Clair's  defeat  by  the  In- 
dians. One  of  the  red  warriors  threw  his  tomahawk  at 
our  retreating  patient,  the  head  of  which  struck  him 
violently  in  the  lower  part  of  the  belly,  and  caused  a 
rupture. 

He  has  been  able  to  reduce  the  contents  of  the  sac 
until  within  the  last  three  years,  since  which  a  portion 
has  been  irreducible.  A  few  days  since,  while  at  Flat- 
bush,  on  Long  Island,  he  fell  from  a  barn;  the  hernia 
immediately  increased  in  size,  and  he  w-as  unable  to 
put  it  back.     He  then  went  to  New  York,  and  from 


204  ANOMALOUS  CASES. 

thence  walked  to  Philadelphia.  He  had  been  in  the  city 
one  or  two  days  before  his  admission  into  the  Alms- 
house on  the  19th.  In  the  evening,  one  of  the  house 
pupils  discovered  that  the  hernia  was  strangulated.  His 
bowels  were  constipated,  and  he  had  vomiting. 

In  the  morning  I  was  sent  for,  and  Dr.  Hewson  saw 
him  in  consultation.  The  tumour  was  large,  and  evi- 
dently contained  fluid,  it  was  tender  to  the  touch,  and 
the  skin  covering  it  was  somewhat  discoloured.  The 
abdomen  was  tender  on  pressure,  but  not  tumid.  The 
pulse  and  symptoms  generally,  did  not  indicate  a  state 
of  great  danger. 

We  directed  enemata  of  a  strong  decoction  of  senna- 
leaves,  and  advised  that  the  patient  should  be  placed 
in  a  warm  bath,  and  while  in  the  bath  should  try  the 
taxis  himself. 

It  was  concluded  to  meet  at  3  o'clock  in  the  after- 
noon. But  just  before  this  time,  the  patient  unexpect- 
edly expired.  He  had  been  in  the  warm  bath  for  about 
fifteen  minutes,  and  attempted  reduction  by  the  taxis. 
He  complained  of  feeling  sick  in  the  bath,  and  was  re- 
moved to  his  bed,  and  about  an  hour  after  he  died. 

Dissection, 
/• 

The  hernial  sac  was  unusually  large,  and  contained 
ten  or  twelves  inches  of  the  small  intestine,  with  a 
great  part  of  the  omentum.  The  bowel  was  in  a  state  of 
complete  gangrene;  the  omentum  appeared  sound,  ex- 
cept a  small  portion  which  was  in  contact  with  the 
bowel.  The  lower  portion  of  the  omentum  was  changed 
in  structure,  as  if  it  had  been  long  excluded  from  the 
abdomen.  The  hernial  sac  was  very  much  contracted 
at  its  lower  portion.    In  the  centre  of  the  contracted 


ANOMALOUS  CASES.  205 

portion  there  was  a  round  aperture  about  the  size  of  a 
dollar.  This  contraction  presented  the  appearance  of 
two  sacs  communicating  by  an  orifice.  The  lower  sac 
contained  that  part  of  the  omentum  which  was  hard, 
and  had  been  irreducible.  The  large  mass  which  had 
recently  descended,  was  contained  in  the  upper  por- 
tion. Marks  of  extensive  peritoneal  inflammation  were 
observed  in  the  abdomen,  and  adhesions  were  formed 
amongst  the  intestines.  Owing  to  the  strangulation  of 
so  large  a  portion  of  omentum,  the  arch  of  the  colon 
was  drawn  towards  the  abdominal  ring,  and  the  sto- 
mach was  displaced  from  its  natural  position. 


CASE  XLI. 

^    Hernia — Semi-Strangulation, 

12ih  mo.  2d,  1820.  I  was  called  this  morning  to  see 
J.  P.,  a  black  man,  at  the  Philadelphia  Almshouse.  He 
was  labouring  under  a  hernia.  The  descent  of  the 
parts  had  taken  place  two  days  before. 

The  tumour  was  large  and  tender;  the  abdomen 
rather  tense;  the  tongue  furred;  the  pulse  not  much 
excited;  and  there  was  no  vomiting. 

I  ordered  the  patient  to  be  placed  in  a  warm  bath, 
and  directed  castor  oil,  of  which  he  took  two  ounces. 
He  had  previously  had  an  enema,  which  had  operated 
twice.  In  the  afternoon,  as  the  oil  had  not  produced  its 
effect,  ordered  jalap  gr.  x.  with  crem.  tart.  9i.  to  be 
taken  every  hour.  At  9  o'clock  in  the  evening,  the  or- 
derly man  reported  that  the  patient  had  had  two  free 


206  ANOMALOUS  CASES. 

stools.  The  hernia  was  still  down;  the  abdomen  tense, 
and  tender  on  pressure;  the  tongue  much  furred.  The 
symptoms  were  so  threatening,  that  my  colleagues  in 
consultation  entertained  serious  views  of  the  propriety 
of  an  operation.  I  rested  my  opinion  in  favor  of  delay, 
upon  the  fact  of  the  patient  having  had  free  stools;  for, 
indeed,  what  more  could  an  operation  effect  than  this? 
It  was  agreed  to  watch  the  case,  and  consult  again  if 
necessary;  and  the  jalap  and  cream  of  tartar  were  con- 
tinued. 

3d.  Morning.  The  patient  was  freely  purged  by  the 
medicine.  The  hernia  was  still  down,  but  the  abdomen 
had  lost  its  tension,  and  was  now  flaccid.  In  the  evening 
I  returned  the  protruded  parts  into  the  cavity  of  the 
abdomen  very  easily,  and  applied  a  truss. 

4th.  I  found  my  patient  well. 


CASE  XLII. 

Mortified  Spot  producing  death — Hydatid  in  the  Sac. 

On  the  morning  of  the  21st  of  8th  mo.  180G,  I  visited 
E.  F.,  a  delicate  woman  aged  about  forty-five  years, 
residing  in  La3titia  court.  She  stated  that  she  had  been 
subject  to  hernial  descents  for  the  last  two  years,  but 
had  always  succeeded  in  returning  the  bowel  without 
medical  aid. 

The  present  attack  commenced  on  the  night  of  the 
17th  instant.  She  had  a  discharge  from  the  bowels  im- 
mediately after  strangulation,  but  none  since.  The  only 
medicine  she  had  taken  was  a  dose  of  salts,  and  herb 


ANOMALOUS  CASES.  207 

teas  prepared  by  her  neighbours.  The  tumour  was  tense  * 
and  painful  to  the  touch;  the  tongue  was  furred;  and 
the  pulse  moderately  tense.  I  bled  her  about  oxii.;  she 
complained  of  being  sick.  I  then  attempted  the  reduc- 
tion by  taxis,  but  failed.  I  directed  ice  to  be  applied  to 
the  tumour,  a  purgative  enema,  and  small  doses  of 
jalap  and  cream  of  tartar,  with  oil  of  cinnamon  every 
two  hours.  I  visited  her  again  in  about  four  hours. 
The  tumour  was  more  flaccid.  I  again  tried  the  taxis 
without  effect.  The  powders  had  been  rejected  by  the 
stomach.  I  directed  the  warm  bath,  and  a  continuation 
of  ice  to  the  tumour. 

I  again  visited  her  in  about  four  hours.  Her  appear- 
ance was  now  more  alarming.  The  pulse  was  sinking, 
the  vomiting  continued,  and  the  hernia  remained  irre- 
ducible. A  consultation  was  called  of  Drs.  Griffitts, 
Hewson  and  Dorsey,  who  met  me  in  a  short  time.  But 
the  change  was  so  great  that  it  was  thought  most  pru- 
dent not  to  attempt  the  operation. 

In  a  few  hours  after  she  died. 

Dissection. 

On  dissecting  off"  the  integuments,  the  tumour  pre- 
sented a  purplish  appearance.  On  opening  the  sac,  a 
quantity  of  bloody  serum  escaped.  A  very  small  portion 
of  small  intestine  was  involved  in  the  stricture,  which 
was  in  a  gangrenous  state.  Appended  to  this  was  a 
hydatid  of  considerahle  size.  The  intestines  above  the 
strictured  part  were  distended  with  flatus.  The  appear- 
ances of  inflammation  within  the  cavity  of  the  abdomen 
were  very  slight. 


CONCLUSION. 

From  the  preceding?  views,  predicated  on  a  variety 
of  cases  narrated  in  this  work,  the  author  has  deemed 
it  expedient  to  submit,  in  the  form  of  corollaries,  a 
series  of  practical  precepts,  which  may,  perhaps,  prove 
important  as  a  guide  to  the  young  practitioner. 

In  every  case  of  colic,  always  suspect  strangulated 
hernia. 

Be  not  deceived  by  a  free  operation  from  the  bowels; 
for  it  generally  takes  place  directly  after  the  occurrence 
of  strangulation. 

The  symptoms  of  strangulation  are  sometimes  more 
violent  and  dangerous  in  a  small  than  a  large  hernia. 

Guard  most  carefully  against  the  employment  of  force 
in  the  taxis.  Long-continued  and  injudicious  efforts  to 
procure  the  reduction  of  a  strangulated  bowel  by  taxis, 
must  greatly  increase  the  danger  of  the  patient.  The 
experience  of  Dessault  on  this  subject  is  worthy  of  con- 
stant remembrance — "  You  may  always  hope  for  suc- 
cess in  a  hernia  which  has  not  been  touched  before 
operating."  A  patient  who  has  long  been  accustomed 
to  put  up  his  own  rupture,  will  generally  perform  the 
taxis  much  better  and  more  safely  for  himself,  than  any 
surgeon  can  do  it  for  him.  Let  not  professional  pride 
interfere  with  the  dictates  of  common  sense,  and  the 
voice  of  humanity. 

In  old,  or  delicate  and  feeble  subjects,  have  a  care 
about  using  violent  remedies  to  reduce  the  strangulated 


COROLLARIES.  209 

parts,  especially  a  short  time  before  the  operation. 
They  may  exhaust  the  vital  energies.  The  lancet  may 
be  carried  too  far.  In  some  subjects  the  tobacco  injec- 
tion is  far  more  to  be  dreaded,  than  the  operation  when 
properly  performed. 

Cases  of  concealed  hernia  call  for  the  most  accurate 
examination  of  the  parts.  The  stricture  may  exist  at 
the  internal  ring,  and  may  readily  elude  a  superficial  in- 
spection. 

When  the  symptoms  are  urgent,  "  delays  are  dan- 
gerous." 

Remember  the  expressions  of  the  experienced  and 
judicious  W.  Hey,  of  Leeds:  "  I  have  often  had 
occasion  to  regret  that  I  performed  the  operation  too 
late,  but  never  that  I  performed  it  too  early." 

Give  a  full,  clear,  and  candid  statement  of  the  case 
to  the  patient  and  his  friends  before  the  operation. 
Carefully  avoid  technicalities.  Clothe  ideas  in  language 
that  a  very  plain  capacity  can  comprehend. 

Shave  the  parts  before  the  operation. 

In  making  the  first  incision  through  the  skin  over  the 
tumour,  let  it  be  well  pinched  up  as  directed  in  the  ope- 
ration. Use  a  sharp-pointed  bistoury  with  its  back  to- 
wards the  hernial  tumour.     . 

Secure  all  blood-vessels  that  may  be  of  sufficient  size 
to  obscure  a  delicate  dissection  by  an  eflfusion  of  blood. 

Be  not  alarmed  about  complicated  layers  of  fasciae; 
they  may  be  cautiously,  but  very  safely  divided,  con- 
formably to  directions  in  the  chapter  on  the  operation. 

Always  open  the  hernial  sac. 

Difficulties  may  arise  from  the  absence  of  fluid,  and 
from  adhesions,  but  these  may  be  safely  overcome. 

In  entero-epiplocele,  there  may  be  a  sac  within  a  sac. 
27 


210  COROLLARIES. 

The  intestine  may  be  entirely  obscured  from  view  by 
the  omentum,  which  covers  it  hke  the  crown  of  an  arch. 
This  must  be  opened  before  the  real  seat  of  stricture 
can  be  ascertained. 

Be  not  alarmed  at  the  bloody  fluid  which  may  escape 
from  the  hernial  sac. 

•Examine  if  the  smell  be  cadaverous. 

After  the  sac  is  so  far  opened  as  to  admit  the  index 
finger,  always  bear  in  mind  that  this  is  the  best  director. 

In  inguinal  hernia  divide  the  stricture  upward. 

In  femoral  hernia  do  the  same. 

Should  the  obturator  artery  present  in  front  of  the 
stricture,  the  utmost  caution  must  be  observed. 

I  would  recommend  for  the  division  of  the  stricture, 
the  curved  and  blunt-pointed  bistoury  guarded  as  di- 
rected, and  would  prefer  a  dull  rather  than  a  sharp 
instrument.  Let  the  stricture  be  gently  divided  by  "?iz6- 
5/m^,"  rather  than  sharp  cutting. 

A  very  slight  division  is  generally  sufficient  to  admit 
the  finger  by  the  side  of  the  bowel  into  the  cavity  of  the 
abdomen. 

Should  a  thick  coat  of  lymph  be  eflfused  over  the 
strangulated  parts,  remove  it  gently  with  the  JIat  handle 
of  the  scalpel  and  the  fingers. 

Be  exceedingly  tender  in  the  separation  of  adhesions. 

Remember  that  the  signs  of  mortification  as  set  down 
in  books  are  very  uncertain.  The  usual  symptoms  may 
appear  when  the  bowel  is  not  mortified.  They  may  be 
absent  at  the  very  moment  when  the  bowel  is  mortified. 

Let  not  a  dark  purple  colour  of  the  bowel  or  even 
an  absence  of  circulation,  decide  the  question  of  its  ac- 
tual death. 

Most  scrupulously  refrain  from  making  an  incision 
into  the  bowel  on  incomplete  evidence. 


COROLLARIES.  211 

When  the  bowel  or  the  omentum  arc  found  in  a  state 
of  mortification,  do  not  Hghtly  esteem  the  efforts  of 
•nature,  but  rather  be  cautious  about  the  interference  of 
art.   The  former  is  intuitive,  capable  of  eluding  many 
difficulties,  and  under  very  discouraging  circumstances, 
it  may  produce  the  most  happy  results.      The  latter, 
aided  by  the  lights  of  experience,  and  accompar.ied 
with  sound  discretion,  may  also  accomplish  much,  at  the 
proper  time.     While  in  some  instances,  well  intended, 
yet  officious  interference  with  the  vis  medicatrix  na- 
turae, may  prove  to  be  zeal  without  knowledge,  which 
is  said  to  be  like  courage  in  a  blind  horse. 

Be  especially  careful  to  avoid  the  return  of  expatri- 
ated omentum  into  the  abdominal  cavity,  for  reasons 
already  assigned. 

To  cut  off  a  large  portion  of  omentum  near  its  root, 
and  then  to  return  it  to  its  natural  situation,  subjects 
the  patient  to  the  hazard  of  dangerous  hemorrhage, 
unless  the  bleeding  vessels  be  secured  by  ligatures. 

To  apply  ligatures  to  the  omentum,  and  then  permit 
it  to  recede  into  the  abdomen,  carrying  the  ligatures 
with  it,  is  to  adopt  a  very  dangerous  practice.  It  is 
calculated  to  maintain  the  imperfection  of  a  most  im- 
portant cavity,  and  to  induce  peritoneal  inflammation. 

If  a  necessity  should  arise  during  an  operation  for 
hernia,  to  delay  procedure  for  a  short  time,  cover  the 
wound  with  a  bladder  partly  filled  with  warm  water. 
It  can  be  retained  in  its  position  by  the  hand  of  an 
assistant. 

Permit  not  a  dread  of  the  infammatory  effects  of  opium 
improperly  to  discourage  its  use  in  strangulated  her- 
nia. It  may  be  justly  regarded  as  a  most  valuable  arti- 
cle in  the  treatment  for  reduction,  and  also  before  and 


212  COROLLARIES. 

after  the  operation.  When  an  anodyne  enema  is  used, 
remember  it  is  more  powerful  than  is  generally  sup- 
posed. I  consider  sixty  drops  of  laudanum  by  the  rect 
tum,  quite  equal  to  thirty  by  the  mouth. 

The  operation  for  umbilical  rupture  in  infants,  as 
recommended  by  Dessault,  is  believed  to  be  unneces- 
sary. Nature  is  generally  able  to  effect  the  cure  without 
any  other  assistance  from  art  than  adhesive  strips,  and 
a  bandage;  or  even  without  such  aid. 

When  called  out  into  the  country,  always  carry 
along  a  few  spermaceti  or  wax  candles.  On  this  point 
I  speak  from  experience.  Any  surgeon  who  has  per- 
formed a  delicate  operation  in  the  dead  of  the  night,  in 
some  of  our  farm  houses  by  the  light  of  "  home-made^'' 
candles,  will  Understand  my  meaning. 

After  the  operation,  gentle  laxatives  should  be  used 
instead  of  drastic  purges.  Castor  oil  is  peculiarly  well 
adapted,  or  a  solution  of  manna  and  cream  of  tartar. 

Should  the  symptoms  of  strangulation  continue  Un- 
relieved, the  steady  use  of  extremely  minute  portions  of 
calomel,  as  shown  in  several  cases  that  are  narrated, 
may  produce  a  most  salutary  effect. 

The  diet  should  be  carefully  regulated  until  the  im- 
mediate danger  has  ceased.  Hard  and  indigestible  ali- 
ment is  obviously  improper.  Liquid  and  soft  diet,  adapt- 
ed to  the  stomach  of  the  patient,  is  important,  such  as 
oatmeal  gruel,  sago,  Indian  or  rye  mush,  &c.;  the  latter 
is  gently  aperient,  especially  if  eaten  with  molasses. 


In  giving  the  preceding  corollaries  at  the  close  of 
the  essay  on  hernia,  it  is  hoped  that  the  author  has  not 


COROLLARIES.  213 

exposed  himself  to  the  charge  of  tautology.  There  are 
few  subjects  in  surgery  that  require  a  more  thorough 
and  exact  knowledge  of  all  the  various  and  probable 
difficulties  that  may  arise  during  an  operation,  than 
strangulated  hernia.  The  surgeon  should  be  prepared 
calmly  to  meet,  and  promptly  to  overcome  them.  When 
he  has  a  living  man  lying  before  him  on  the  operating  ta- 
ble, and  has  proceeded  so  far  as  to  have  his  bowels  in  his 
hand,  he  will  then  most  assuriedly  understand  the  ne- 
cessity of  having  al  in  his  own  lamp.  It  would  be  an 
unpropitious  moment  to  abandon  his  patient,  until  he 
could  turn  over  the  pages  of  a  book  to  study  out  the 
course  to  be  pursued.  He  will  then  not  only  see  but  im- 
pressively yee/  the  importance  of  carrying  a  book  in  his 
own  head,  in  order  to  direct  the  movements  of  his  hand. 


PART  II. 


DISEASES  OF  THE  URINARY  ORGANS. 


CHAPTER  I. 


RETENTION  OF  URINE. 


There  is  a  marked  distinction  between  retention  and 
suppression  of  urine.  The  latter  implies  a  want  of 
power  in  the  kidneys  to  secrete  urine.  This  is  well 
understood  by  medical  men  accustomed  to  attend  yel- 
low fever  patients;  and  it  is  generally  a  mortal  symp- 
tom. During  my  residence  in  the  Yellow  Fever  Hos- 
pital, when  a  young  man,  an  opportunity  was  given  of 
observing  the  condition  of  the  bladder  in  this  disease, 
and  of  confirming  it,  after  death,  by  dissection. 

In  retention,  the  kidneys  secrete  urine, which  is  carried 
by  the  ureters  into  the  bladder,  but,  from  causes  here- 
after to  be  developed,  it  cannot  be  discharged.  As  it 
accumulates,  the  viscus  becomes  distended,  and  it  is 
not  uncommon  for  the  bladder  to  rise  a  considerable 
distance  above  the  pubis,  so  as  to  be  distinctly  felt  by 
laying  the  hand  upon  the  abdomen.  The  introduction 
of  the  fincrer  into  the  rectum,  also  enables  the  surireon 
to  ascertain  the  distension  of  the  bladder. 

Patients  affected  with  sudden  retention  of  urine  suffer 
extreme  pain — making  violent  and  ineffectual  attempts 
to  discharije  the  contents  of  the  bladder.  Seldom  do 
we  meet  with  any  description  of  persons  who  have 
stronger  claims  upon  our  active  sympathy,  and  whose 
intense  distress  appeals  more  forcibly  to  the  humanity 
of  the  surgeon. 

28 


218  RETENTION  OF  URINE. 

I  shall  not  attempt  to  enumerate  all  the  causes  of 
retention  of  urine.  An  extended  investigation  of  cases 
in  books,  both  ancient  and  modern,  will  supply  a  variety 
which  may  be  proper  for  a  work  purely  systematical; 
here  it  is  rather  my  object  to  detail  the  results  of  my 
own  observations.  Among  the  more  common  causes, 
particularly  in  old  people  liable  to  the  disease,  damp 
and  cold  feet  may  be  mentioned.  Long-continued  and 
severe  exposure  to  cold  may  excite  a  spasm  and  rigidity 
in  the  urinary  organs,  causing  retention  and  severe 
pain.  Stricture  of  the  urethra,  accidents  involving 
fractures  of  the  pelvis,  contusions  and  lacerations  of 
the  abdomen  and  perineum,  and  an  enlarged  and  tumid 
state  of  the  prostate  gland,  will  be  found  among  the 
causes  of  retention  discussed  in  the  following  pages. 


SECTION  I. 


DECEPTIVE  SYMPTOMS. 


Before  entering  upon  the  recital  of  particular  cases 
illustrating  the  causes  which  have  been  enumerated,  it 
will  be  proper  to  notice  the  subject  of  deceptive  symp- 
toms in  retention  of  urine.  Unless  the  practitioner  is 
thoroughly  acquainted  with  this  part  of  the  subject,  he 
may  be  completely  deceived.  His  sagacity  and  skill 
may  be  called  in  question,  and  the  suffering  and  even 
danger  of  his  patient  may  be  greatly  increased,  by  the 
improper  delay  of  efficient  treatment. 

After  the  bladder  has  reached  a  certain  point  of  dis- 


DECEPTIVE  SYMPTOMS.  219 

tension,  a  copious  flow  of  urine  frequently  occurs.  This 
may  induce  the  medical  attendant  to  believe  that  the 
obstruction  has  been  overcome,  and  that  the  disease 
has  terminated  happily.  The  experienced  surgeon,  how- 
ever, is  always  on  the  alert:  he  ascertains  that  the  flow 
of  urine  is  involuntary ;  he  places  his  hand  over  the  pubic 
region,  and  feels  the  distended  bladder,  which  is  pain- 
ful on  pressure;  he  soon  discovers  that  the  patient  is 
not  relieved.  Under  these  circumstances  a  fatal  termi- 
nation of  the  case  may  be  expected,  unless  prompt  and 
judicious  practice  be  adopted. 

Another  condition  of  the  bladder  may  occur,  still 
more  deceptive  than  the  preceding;  and  it  may  elude 
the  vigilance  even  of  a  watchful  sentinel.  The  bladder 
may  discharge  a  portion  of  the  urine  under  the  influ- 
ence of  the  will,  and  may  still  continue  to  retain  a  part 
until  it  becomes  largely  distended.  It  may  be  thus  gra- 
dually and  habitually  inducted  into  a  state  of  insensi- 
bility, which  will  admit  of  very  unnatural  distension. 
All  this  may  take  place  without  the  intense  suffering 
and  immediate  danger  which  accompanies  the  disease 
when  it  occurs  suddenlv.  Instances  of  this  kind  exist- 
ing  among  patients  affected  with  chronic  disease  about 
the  neck  of  the  bladder,  particularly  the  prostate  gland, 
are  well  known  to  surgeons. 

My  preceptor,  the  late  venerated  Dr.Wistar,  used  to 
relate  a  case  of  this  kind.  A  respectable  old  citizen,  a 
judge  in  one  of  our  courts,  was  labouring  under  dis- 
ease of  the  prostate  gland.  On  one  occasion,  while  the 
Doctor  was  in  attendance,  he  made  regular  and  minute 
inquiries  of  his  patient,  in  regard  to  the  discharge  of 
his  urine.  During  an  attendance  of  many  days,  he  was 
informed  by  the  patient  that  he  discharged  his  urine  at 


220  DECEPTIVE  SYMPTOBIS. 

pleasure;  but  certain  symptoms  induced  the  Doctor  to 
examine  for  himself,  when,  to  his  surprise,  he  found 
that  the  bladder  had  risen  considerably  above  the  pubis. 
He  at  once  introduced  a  catheter,  and  drew  off  nearly 
two  quarts  of  urine. 

This  deception  may  exist  even  in  cases  of  an  acute 
and  recent  character:  the  bladder  may  evacuate  a 
part  of  its  contents  under  the  influence  of  the  will,  and 
yet  may  retain  enough  to  cause  an  enormous  and  fatal 
distension  of  this  viscus.  This  I  have  seen,  not  only  in 
adults,  but  also  in  a  tender  infant — not  in  the  tenth 
year,  or  tenth  month,  but  on  the  tenth  day  of  its  life. 
Cases  of  this  will  appear  in  their  proper  place:  that  of 
the  infant  has  been  published  by  Dr.  Dewees,  and  has 
been  disputed  in  a  foreign  journal;  but,  as  the  surgeon 
who  introduced  the  catheter,  I  do  positively  attest  the 
fact.  The  urine  was  put  into  a  bottle,  corked  and  sealed, 
then  weighed,  and  it  is  now  in  my  possession.  I  fully 
admit  that  the  case  is  of  a  most  uncommon  character; 
but  where  the  narrators  are  known,  it  will  be  ac- 
credited. 


CASE  I. 

Enormous  distension  of  the  Bladder — Uri7ie  discharged 
under  the  injluence  of  the  will — Death. 

Columbia,  on  the  banks  of  the  Susquehanna,  Lan- 
caster county,  Pennsylvania,  6th  mo.  26th,  1812.  Being 
on  a  visit  to  my  relatives  in  this  place,  I  was  requested 
by  Dr.  H.  M'Corklc,  a  practitioner  in  the  town,  to  visit 


de;ceptive  symptoms.  221 

with  him,  a  female  patient,  whom  he  had  been  attend- 
ing for  several  weeks,  with  a  low  nervous  fever. 

Dr.  Thomas  Griffith,  of  the  same  place,  had  visited 
her  with  him  several  times,  in  consultation.  About  ten 
days  previously  to  my  seeing  the  patient,  Dr.'  M'C.  had 
perceived  a  tumour  in  the  abdomen,  which  had  not 
risen  far  above  the  pubis;  but  had  been  steadily  increas- 
ing, accompanied  with  considerable  tenderness  of  the 
abdomen  on  pressure.  As  the  case  was  obscure  to  the 
physicians  in  attendance,  my  opinion  was  requested. 

The  patient  was  a  young  married  woman,  delicate 
in  her  frame,  and  the  mother  of  three  children.  Her 
skin  was  cool;  pulse  very  frequent  and  feeble;  tongue 
moist,  moderately  furred,  and  of  a  light-brown  colour 
in  the  middle.  She  was  in  a  very  exhausted  state.  On 
examining  the  abdomen,  one  might  readily  have  sup- 
posed, from  the  size  of  the  tumour,  that  the  patient  was 
almost  in  the  last  stage  of  utero  gestation.  I  could  dis- 
tinctly perceive  the  fluctuation  of  a  fluid,  and  should 
have  supposed  the  case  to  be  ascites;  but  on  carefully 
passing  my  hand  over  the  abdomen,  I  clearly  dis- 
covered a  circumscribed  tumour.  Between  the  superior 
part  of  the  tumour,  and  the  termination  of  the  xiphoid 
cartilage,  there  was  a  small  space,  -which  retained  its 
natural  appearance,  which  could  not  have  been  the 
case,  had  the  swelling  arisen  from  a  general  effusion  of 
fluid  within  the  abdominal  cavity.  As  the  tumour  occu- 
pied the  anterior  and  central  part  of  the  abdomen,  it 
was  not  likely  to  be  ovarian  dropsy,  nor  would  the  his- 
tory of  the  case  justify  such  a  conclusion. 

My  attention  was  now  directed  to  the  bladder.  On 
inquiry,  I  was  assured  that  the  patient  passed  urine  in 
considerable  quantities^  and  under  the  injluence  of  the  will. 


222  DECEPTIVE  SYMPTOMS. 

But  knovviniij  that  this  mi^ht  occur  while  the  bladder  is 
suffering  from  great  distension,  I  advised  the  introduc- 
tion of  the  catheter.  We  gave  her  a  few  drops  of  lau- 
danum, and  at  the  request  of  the  attending  physician, 
I  introduced  the  instrument  without  the  slightest  diffi- 
culty. Very  high-coloured  urine  began  to  flow  through 
the  catheter,  and  as  it  flowed  the  tumefaction  of  the 
abdomen  gradually  lessened.  After  about  two  quarts 
had  passed  off",  a  paroxysm  of  extreme  restlessness 
occurred.  The  patient  insisted  on  rising  from  bed,  and 
no  persuasions  could  induce  her  to  remain  quiet.  I  was 
under  the  necessity  of  withdrawing  the  catheter.  Her 
exertions  evidently  exhausted  her.  She  sat  upon  the 
close  stool,  and  had  a  slight  discharge  from  the  bowels. 
The  pulse  sank;  cordials  were  exhibited;  but  all  eflbrts 
to  arouse  the  system  failed,  and  in  a  few  minutes  she 
expired. 

In  order  to  guard  against  debility,  arising  from  a 
removal  of  distension,  a  broad  bandage  was  passed 
around  the  abdomen,  as  in  tapping  for  dropsy,  before 
she  was  permitted  to  sit  erect.  I  think  it  probable  that 
several  quarts  of  urine  remained  in  the  bladder.  Per- 
mission was  asked  to  open  the  body,  but  was  not 
obtained. 


CASE  II. 

Retention  in  an  Infmit — Bladder  greatly   distended — 

Death. 

6th  mo.  25th,  1822.    I  was  called  by  Dr.  W.  P.  De- 
wees,  to  visit  a  female  infant  of  G.  D.  B.,  on  the  tenth 


DECEPTIVE  SYMPTOMS.  223 

day  after  its  birth.     The  history  of  the  case  is  as  fol- 
lows: 

At  birth  the  child  was  firm  and  plump,  and  continued 
healthy  for  several  days.  It  passed  urine  freely.  On 
the  night  of  the  20th  it  was  very  uneasy;  the  next  day 
it  cried  very  much,  and  appeared  to  be  in  great  pain, 
which  came  on  in  paroxysms.  It  passed  no  urine.  The 
parents  remarked,  that  the  infant  had  evidently  shrunk, 
and  was  now  smaller  than  at  birth.  It  continued  in  this 
state  until  the  morning  of  the  25th,  the  child  getting 
worse,  and  being  at  times  in  great  agony.  The  stools 
were  as  green  as  the  expressed  juice  of  rue. 

When  I  saw  the  patient,  the  belly  was  enormously 
distended,  and  the  veins  on  the  surface  were  greatly 
enlarged.  Dr.  Dewees  had  left  a  note,  stating  the  case, 
and  requesting  me  to  be  provided  with  a  small  catheter, 
as  he  was  under  the  impression  that  the  bladder  was 
distended.  I  introduced  a  very  small  flexible  gum  cathe- 
ter into  the  bladder;  no  urine  follow  ed,  and  I  was  really 
inclined  to  the  opinion  that  the  distension  arose  from 
some  other  cause;  but  Dr.  D.  being  convinced  that  the 
tumour  arose  from  distended  bladder,  I  withdrew  the 
tube,  and  on  carefully  examining  it,  I  found  it  was  some- 
what obstructed.  As  it  w^as  so  very  small,  the  slightest 
impediment  would  prevent  the  passage  of  urine  through 
it.  I  had  omitted  to  clear  the  tube,  by  passing  the  sti- 
let  through  it,  before  its  introduction,  which  ought 
always  to  be  done;  from  a  neglect  of  it,  I  might  have 
left  this  patient  under  a  false  impression,  if  Dr.  D.  had 
not  expressed  his  opinion  of  the  case  so  decidedly. 

After  passing  the  stilet  through  the  catheter,  it  was 
introduced  a  second  time,  and  the  urine  then  floAved  in 
a  very  small  stream,  and  ample  evidence  was  furnished 


224  DECEPTIVE  SYMPTOMS. 

of  the  state  of  the  bladder.  As  the  discharge  continued, 
the  tension  of  the  abdomen  diminished,  and  the  child 
actually  fell  asleep  while  the  catheter  was  in  the  blad- 
der. The  bore  of  the  instrument  was  so  small,  that 
about  three  quarters  of  an  hour  elapsed  before  the  con- 
tents of  the  bladder  were  evacuated.  At  the  close  of 
the  operation  the  distension  of  the  abdomen  had  entirely 
subsided,  and  on  measuring  the  quantity  of  urine  which 
had  been  drawn  off  from  this  tender  infant,  it  actually 
measured  eighteen  and  a  half  ounces  avoirdupois  "weight. 
26th.  Drew^  away  by  the  catheter  several  ounces  of 
urine  in  the  morning,  and  again  in  the  evening.  The 
mouth  and  tongue  of  the  little  patient  are  covered  with 
aphthous  sores.  The  labia3  pudenda — which  were  pro- 
tuberant, and  much  inflamed  previous  to  the  introduc- 
tion of  the  catheter — have  improved  in  appearance. 

27th.  The  aphthous  disease  appeared  to  have  extended 
through  the  route  of  the  ahmentary  canal,  and  this  day 
the  patient  died. 


CASE  III. 


Incontinence^  with  Retention  of  Urine. 
Girardwas  admitted  as  a  patient  into  the  Penn- 


sylvania Hospital  sometime  in  the  \2th  rno.  1824,  la- 
bouring under  an  incontinence  of  urine  of  some  months 
standing.  Two  or  three  days  after  his  admission,  he  drew 
my  attention  to  a  swelling  of  his  abdomen,  which  he 
said  had  existed  for  some  time.  It  presented  very  much 
the  appearance  of  the  abdomen  of  a  woman  somewhat 


DECEPTIVE  SYMPTOMS.  225 

advanced  in  pregnancy.  A  hard  tumour  extending 
above  the  umbihcus,  and  having  some  little  elasticity, 
led  to  the  introduction  of  a  catheter,  and  at  least  three 
quarts  of  urine  were  drawn  off'  by  the  instrument,  to  the 
great  relief  of  the  patient.  After  this,  the  catheter  was 
introduced  twice  in  every  twenty-four  hours,  for  a 
length  of  time,  and  about  half  a  gallon  of  urine  was 
evacuated  at  each  operation.  The  patient  finally  reco- 
vered. 


CASE  IV. 

Retention  fromExhaustion  and  Nervous  Irritation —  Urine 
Discharged  under  Injiuence  of  the  Will. 

12th  mo.  2d,  1830.  G.  M*C.,  a  member  of  the  le^is- 
lature  from  the  interior  of  the  state,  came  to  the  city  to 
consult  Dr.  Physick  and  myself.  He  had  been  for  a 
long  time  subject  to  hemorrhoids,  which  had  been 
attended  with  profuse  hemorrhage,  by  which  he  had 
been  nearly  exhausted. 

He  was  extremely  pale,  was  affected  with  violent  pal- 
pitation of  the  heart;  vertigo;  hurried  respiration  after 
the  least  exertion;  throbbing  of  the  temporal  arteries; 
frequent  attacks  of  cough;  nausea  and  vomiting;  severe 
erratic  pains;  oedematous  limbs;  and  a  sensation  of 
fulness  in  the  cardiac  region. 

On  the  3d,  assisted  by  Dr.  Physick,  I  passed  two  wire 
ligatures  around  the  hemorrhoidal  tumours.  On  the 
next  day  his  exhaustion  was  extreme,  accompanied  w^ith 
restlessness  and  delirium.     While  I  was  with  him,  he 

29 


226  DECEPTIVE  SYMPTOMS. 

passed,  under  the  influence  of  the  will,  a  considerable 
quantity  of  pale  urine;  but  as  his  restlessness  was  un- 
abated, I  was  induced  to  suspect  that  the  bladder 
was  not  yet  relieved.  A  close  examination  proved 
that  my  suspicions  were  correct.  I  immediately  intro- 
duced a  catheter,  and  drew  oft'  at  least  a  quart  of  urine, 
to  the  great  relief  of  the  patient.  His  restlessness  and 
delirium  subsided,  and  he  fell  into  a  tranquil  slumber. 


CASE  V. 


Incontinence  and  Retention  of  Urine. 

llth  mo.  11th,  1834.  1  was  consulted  by  J.  H.  C,  a 
respectable  merchant,  labouring  under  incontinence  of 
urine,  attended  with  considerable  pain.  I  had  several 
times  prescribed  for  this  individual,  during  the  past  year 
or  two,  for  symptoms  denoting  irritable  bladder,  of 
which  he  had  been  relieved  by  diluent  drinks,  venesec- 
tion, &c.  I  found  he  had  been  suffering  for  several 
days  from  great  difficulty  in  voiding  his  urine.  He  felt 
an  inclination  to  urinate  every  twenty  or  thirty  minutes, 
and  passed  but  a  small  quantity  at  each  attempt.  He 
was  unable  at  this  time,  to  pass  his  water,  while  stand- 
ing, without  having  a  discharge  from  his  bowels.  I 
explained  to  him  my  views  of  his  case,  and  advised  him 
to  allow  me  to  introduce  a  catheter;  he  was  very  anx- 
ious, however,  that  some  other  means  should  be  tried, 
from  a  dread  of  the  instrument  and  from  a  fear  that  his 
accustomed  occupation  would  be  interrupted.  I  di- 
rected him  to  be  bled;  to  drink  freely  of  flaxseed-tea; 


RETENTION  FROM  COLD.  227 

and  to  use  anodynes.  As  he  was  very  improperly  serv- 
ing on  a  jury  in  one  of  our  courts,  I  did  not  see  him 
for  several  days.  On  being  sent  for  again,  I  found  the 
irritation  had  increased  so  much,  that  on  every  attempt 
to  void  urine  he  was  threatened  with  a  discharge  from 
the  bowels.  His  appetite  had  failed;  his  pulse  was  quite 
feeble;  and  he  was  somewhat  emaciated.  As  he  was 
discharging  his  urine  frequently  at  this  time,  he  could 
not  suppose  that  his  bladder  was  distended;  but  on  in- 
troducing the  catheter,  I  drew  off  about  half  a  gallon 
of  water,  to  his  great  surprise  and  relief. 

The  operation  w^as  repeated  for  several  weeks,  morn- 
ing and  evening,  by  myself  or  son.  At  each  intro- 
duction a  large  quantity  was  drawn  off,  although  he 
continued  to  discharge  urine  during  the  intervals.  I 
instructed  him  in  the  manner  of  introducing  the  in- 
strument for  himself,  with  which  he  soon  became  fami- 
liar, and  he  then  used  it,  generally  three  times  every 
day,  drawing  off  in  this  manner,  about  three  pints,  and 
discharging  in  the  natural  way  about  one  pint. 

He  still  continues  this  practice.  His  health  is  very 
much  improved,  and  he  is  able  to  attend  to  some  busi- 
ness. 


SECTION  II. 


RETENTION   FROM  THE  EFFECTS  OF  COLD. 

Long  continued,  and  also  sudden  exposure  to  cold, 
may  bring  on  severe  spasmodic  contraction  of  the 
urethra,  causing   retention   of  urine,  and   much  dis- 


^28  RETENTION  FROM  COLD. 

tress  to  the  patient.  These  are  instances  in  which  sti- 
mulants may  sometimes  be  employed  with  advantage. 
In  illustration  of  this  point,  I  will  introduce  the  follow- 
ing case. 


CASE  VI. 

Retention  from  Cold. 

Many  years  ago,  one  very  cold  night,  I  was  called 
from  my  bed  by  a  watchman,  who  said  he  had  with 
him  a  man  who  could  not  pass  his  urine.  As  I  resided 
at  no  great  distance  from  the  watch-house,  and  was  apt 
to  be  called  up  by  the  city  watch  in  cases  of  trouble 
among  their  prisoners,  I  felt  much  inclined  to  remain 
in  a  warm  bed  during  such  an  inclement  night.  I  advised 
the  officer  to  carry  the  man  to  the  watch-house,  and 
keep  him  in  a  warm  room;  promising  that  I  would  call 
in  the  morning,  and  have  him  conveyed  to  the  Infirm- 
ary. The  poor  suffering  patient,  however,  felt  himself  a 
party  concerned  in  the  case,  he  fixed  himself  down  on 
a  bench  at  the  door,  and  was  determined  to  give  a  voice 
on  the  occasion.  He  immediately  commenced  a  howling 
under  the  window  very  analagous  to  that  of  a  large  dog. 
It  was  sufficient  to  disturb  the  neighbourhood.  I  was 
compelled  to  appease  him  by  an  assurance  that  I  would 
come  down  and  attend  to  his  case.  I  soon  had  cause 
to  rejoice  that  I  listened  to  his  complaints.  He  entered 
my  house — he  was  completely  chilled,  his  bare  skin 
visible  through  his  tattered  garments — his  condition 
was  a  fair  example  of  human  degradation  and  wretch- 
edness. 


RETENTION  OF  URINE  IN  FEVER.  229 

I  attempted  to  pass  the  catheter,  but  the  urethra  was 
in  such  a  state  of  spasmodic  contraction,  that  it  was 
impossible.  I  procured  for  him  some  gin;  the  poor 
wretch  swallowed  it  with  avidity;  he  took  two  glasses. 
After  warming  him,  I  sent  him  to  the  Hospital,  accom- 
panied with  a  note  to  the  house-surgeon,  and  then  slept 
myself  more  soundly  than  I  should  have  done  had  I 
turned  a  deaf  ear  to  his  cries.  Next  morning  I  found 
all  the  difficulty  was  terminated.  The  spasm  was  re- 
laxed and  the  urine  passed  freely.  Here  the  gin  was 
useful;  but  very  great  caution  is  required  in  employing 
such  a  remedy  in  ordinary  cases. 


SECTION  III. 


RETENTION  OF  URINE  IN  FEVER. 

When  we  contemplate  the  varied  conditions  of  the 
system  as  displayed  in  the  progress  of  febrile  diseases — 
when  we  discover  the  chain  of  healthy  associations  to 
be  broken,  and  a  new  order  of  morbid  and  irregular 
actions  to  arise  and  gain  the  ascendancy,  it  ought  not 
to  be  a  matter  of  surprise  that  the  urinary  organs  should 
participate  in  the  general  derangement.  It  is  certainly 
a  source  of  regret  that  this  simple  foct  is  too  often 
overlooked  by  attending  physicians — more  especially 
by  those  who  are  not  familiar  with  surgical  practice. 

The  condition  of  the  bowels  in  cases  of  fever,  is 
deemed  a  most  important  subject  of  attention  by  every 
judicious  practitioner.     The  alvine  discharges  are  in- 


230  RETENTION  OF 

spected;  inquiry  as  to  the  quantity,  colour,  and  fre- 
quency of  stools;  voluntary  or  involuntary;  all  these 
follow  as  natural,  every-day  questions,  in  our  attend- 
ance on  fever  patients.  Great  irregularity  in  these  re- 
spects is  often  observed;  and,  especially  when  delirium 
occurs,  the  most  ample  evidence  is  afforded  that  con- 
stant attention  on  the  part  of  the  physician  and  nurse 
is  absolutely  necessary. 

Should  these  inquiries  be  neglected,  the  medical  at- 
tendant would  probably  soon  make  himself  the  subject 
of  severe  and  just  criticism,  by  that  important  and  use- 
ful class  of  assistants  in  the  chambers  of  the  sick — 
intelligent  matrons  and  nurses. 

Happy  would  it  be  for  many  a  suffering  patient,  if 
the  morbid  condition  of  the  urinary  organs  were  as 
closely  investigated  by  physicians  and  nurses,  as  the 
disorders  of  the  alimentary  canal !  This  declaration  is 
predicated,  not  upon  the  experience  of  a  day,  but  its 
truth  has  been  established  in  my  mind  by  many  years 
of  observation.  I  offer  it  as  a  decided  opinion,  that 
many  a  patient  has  suffered  extremely  in  the  progress 
of  fever,  from  this  unsuspected  cause.  His  primary 
disease  has  been  aggravated,  and  his  danger  increased 
for  want  of  a  true  understanding  of  his  actual  condi- 
tion. The  urinary  bladder  may  be  even  fatally  dis- 
tended without  a  suspicion  being  excited  as  to  the  fact; 
more  especially  if  the  patient  be  in  a  state  of  delirium. 
Every  experienced  surgeon  is  famihar  with  this  subject, 
while  with  the  mere  physician  it  may  pass  without  due 
attention. 

The  following  cases  afford  examples  of  this  condi- 
tion of  the  bladder  in  fever. 


URINE  IN  FEVER.  231 


CASE  VII. 


Retention  in  Fever. 

I  was  called  some  years  ago,  in  consultation  with  Drs. 
Fairlamb  and  Coates,  of  Chester  county,  to  visit  a  re- 
spectable old  miller,  residing  thirty-two  miles  from  the 
city.  A  letter  from  his  attending  physician  was  received, 
stating  that  the  patient  had  fever,  and  in  the  course  of 
his  description  of  symptoms,  he  mentioned  that  there  was 
incontinence  of  urine.  I  at  once  anticipated  the  state  of 
the  case,  and  according  to  my  invariable  custom,  went 
provided  with  catheters.  On  examining  the  patient  my 
suspicions  were  fully  realized,  the  bladder  was  dis- 
tended although  urine  flowed  from  the  patient.  I  intro- 
duced a  catheter,  and  drew  off  the  accumulated  urine, 
to  the  great  relief  of  the  old  man,  although  he  died  some 
time  afterward  with  his  primary  disease. 


CASE  VIII. 


Retention  in  Fever. 


In  the  summer  of  1819,  M.P.,  one  of  my  pupils,  was  the 
subject  of  a  dangerous  and  protracted  fever  of  a  remit- 
tent form,  accompanied  with  great  nervous  irritation, 
without  delirium.  My  departed  friend  Dr.  Samuel  P. 
Griffitts,  kindly  aided  me  in  consultation. 


232  RETENTION  OF 

In  the  course  of  the  fever,  the  bladder  participated  in 
the  derangement  of  the  system,  and  he  was  unable  to 
expel  its  contents.  I  was  under  the  necessity  of  intro- 
ducing the  catheter,  through  which  the  urine  flowed 
freely,  to  the  great  relief  of  the  patient;  the  use  of  the 
instrument  was  continued  several  times  in  twenty-four 
hours,  for  at  least  ten  days.  He  gradually  recovered 
from  the  fever,  and  acquired  the  natural  power  over 
the  bladder. 


CASE  IX. 

Retention  in  Fever — Deceptive  Symptoms. 

In  the  year  1832, 1  was  called  in  consultation  with 
my  friend  Dr.  Otto,  to  see  J.  F.,  a  young  merchant. 

He  had  been  the  subject  of  a  severe  fever  for  some 
days,  and  was  involved  in  great  danger.  At  one  period 
he  had  delirium,  was  exceedingly  restless,  and  distressed. 
We  suspected  distension  of  the  bladder,  but  on  making 
inquiry  of  the  nurse,  were  assured  that  he  passed  his 
urine,  and  if  I  recollect  rightly,  it  was  submitted  in  a 
vessel  for  gur  inspection;  but  such  was  the  restlessness 
of  the  patient,  that  an  accurate  examination  was  deter- 
mined on  in  consultation. 

The  tumid  state  of  the  abdomen  above  the  pubis, 
accompanied  with  tenderness  on  pressure,  left  no  doubt 
on  our  minds  as  to  the  cause  of  these  symptoms.  A 
catheter  was  introduced,  and  a  considerable  quantity 
of  urine  was  discharged.     The  operation  was  followed 


URINE  FROM  CONTUSIONS.  233 

by  striking  relief  to  the  patient,  and  a  mitigation  of  his 
alarming  symptoms. 

From  this  period  there  was  a  gradual  amendment; 
but  more  than  a  week  elapsed  before  the  functions  of 
the  bladder  were  so  far  restored  as  to  dispense  with  the 
use  of  the  catheter. 


SECTION  IV. 

RETENTION  FROM  CONTUSIONS  OF  THE  BODY. 

While  I  was  surgeon  to  the  Pennsylvania  Hospital, 
my  services  were  frequently  required  for  patients  who 
had  received  severe  contusions  of  the  abdomen.  The 
extensive  brickyards,  and  gravel  banks,  in  the  imme- 
diate vicinity  of  Philadelphia,  form  a  fruitful  source  of 
accidents  of  this  description.  I  was  early  impressed 
with  the  importance  of  watching  the  condition  of  the 
bladder  in  these  cases.  My  attention  was  particu- 
larly directed  to  this  subject,  in  consequence  of  a  pa- 
tient being  brought  into  the  institution  who  was  caught 
under  a  caving  bank.  On  examination,  we  could  dis- 
cover no  fracture  of  the  pelvis,  though  the  patient  suf- 
fered great  pain,  and  was  unable  to  pass  his  urine.  The 
catheter  was  introduced,  and  frequently  repeated. 
When  reaction  occurred,  there  was  considerable  fever, 
and  blood  was  abstracted.  The  patient  finally  reco- 
vered. 

This  case  induced  the  following  reflections:  If  heavy 
pressure  upon  the  abdomen,  suddenly  induced;  is  suffi- 
cient in  some  instances  to  fracture  the  bones  of  the 

30 


234  RETENTION  FROM 

pelvis,  it  is  easy  to  conceive  that  the  soft  parts,  espe- 
cially the  parietes  of  the  abdomen,  and  even  the  vis- 
cera including  the  bladder,  may  be,  from  the  same 
cause,  involved  in  contusion,  laceration,  and  their  con- 
sequences. 

In  this  condition  of  the  parts,  it  must  be  obvious  that, 
from  the  necessary  contraction  of  the  injured  muscular 
fibres,  the  natural  efforts  for  the  expulsion  of  urine 
from  the  bladder  cannot  be  made  without  greatly  aug- 
menting the  distress  of  the  patient.  Hence  it  may 
happen  that  either  from  inability  on  the  part  of  the  pa- 
tient, or  from  the  dread  of  extreme  pain  resulting  from 
the  contraction  of  the  abdominal  muscles  and  the 
bladder,  the  urine  is  permitted  to  accumulate,  thereby 
increasing  the  suffering  and  danger  produced  by  the 
original  accident. 

A  considerable  number  of  cases  of  this  description 
have  fallen  under  my  observation,  and  I  am  prepared  to 
lay  it  down  as  a  settled  principle,  that  in  every  instance 
of  severe  contusion  of  the  body,  a  steady  watch  should 
be  kept  upon  the  bladder.  If  pain  or  difficulty  attend 
efforts  to  pass  urine,  the  catheter  should  be  invariably 
employed.  By  this  course  the  contused  parts  are  kept  at 
rest,  and  the  danger  of  inflammation  and  fever  is  di- 
minished. 

It  may  also  be  remarked,  that  the  first  effect  pro- 
duced by  a  severe  contusion  of  the  body,  is  to  prostrate 
the  nervous  system,  and  to  induce  severe  pain.  The 
patient  generally  complains  of  chilliness,  his  skin  is 
cold,  the  pulse  feeble,  and  the  features  contracted.  In 
this  condition,  the  practitioner  should  endeavour  to 
allay  pain  by  opiates,  and  wait  for  reaction  of  the  sys- 
tem before  he  attempts  the  abstraction  of  blood.   This 


CONTUSIONS  OF  THE  BODY.  235 

caution  is  rendered  the  more  necessary,  from  the  popu- 
lar cry  for  bleeding,  which  always  prevails,  when  severe 
accidents  of  almost  any  kind  occur. 

When,  in  addition  to  the  injury  of  the  soft  parts,  the 
bones  of  the  pelvis  are  fractured,  it  is  evident  that  the 
contraction  of  the  abdominal  muscles,  will  cause  a 
movement  of  the  fragments  upon  each  other. 

Under  these  circumstances,  the  call  upon  the  surgeon 
is  still  more  imperative,  to  adopt,  and  rigidly  to  adhere 
to  the  practice  of  absolute  quiescence  of  the  injured 
parts  until,  aided  by  time  and  appropriate  treatment, 
nature  shall  accomplish  a  cure. 

This  class  of  accidents  is  sometimes  farther  com- 
plicated by  a  rupture  of  the  urethra. 

To  illustrate  these  latter  conditions,  the  two  follow- 
ing cases  are  presented. 


CASE  X. 

Fracture  of  tJie  Pelvis  and  Ischuria. 

6th  mo.  2d,  1819.  J.  R.,  an  Irish  labourer,  aged  forty- 
five  years,  was  admitted  into  the  Pennsylvania  Hos- 
pital, with  a  fracture  of  the  pelvis  and  contusion  of  the 
abdomen,  caused  by  a  loaded  wagon  passing  over  him. 
He  was  a  patient  of  the  house,  for  some  months  dur- 
ing last  year,  with  chronic  rheumatism.  He  was  slightly 
lame  at  the  time  of  his  discharge  last  autumn.  On 
the  day  of  his  admission,  while  attempting  to  cross  the 
street,  in  front  of  a  loaded  wagon,  drawn  by  five  horses, 
he  was  knocked  down  by  the  leader,  and  the  whole 


236  RETENTION  FROM 

load,  weighing  three  tons,  passed  over  him.  The  wheels 
of  one  side  crossed  the  sacrum  and  ileum  behind,  as  he 
lay  on  his  belly.  He  was  bled  immediately  after  the 
accident,  and  then  carried  to  the  Flospital. 

On  examination,  crepitus  was  discovered  at  the  pos- 
terior edge  of  the  left  os  innomiiiatum,  accompanied 
with  violent  pain  on  both  sides  of  the  pelvis,  about  the 
sacro-iliac  symphysis.  The  patient  was  laid  on  his 
back,  and  supported  by  pillows,  &c.  His  pulse  was 
weak,  and  appeared  for  a  few  minutes  to  be  rapidly 
sinking.  The  extremities  were  cold,  and  the  mind  wan- 
dering, with  a  slight  degree  of  coma. 

Tt.  opii.  gtt.  XXV.  were  given  him,  and  directed  to  be 
repeated  every  six  hours.  No  other  injuries,  except 
bruises,  were  discovered  in  other  parts  of  the  body. 
When  any  attempt  to  move  him  was  made,  he  com- 
plained of  violent  pain  in  the  ascending  ramus  of  the 
pubis.  Some  urine  was  discharged  under  the  influence 
of  the  will,  but  the  bladder  could  not  be  evacuated, 
without  the  frequent  use  of  the  catheter.  The  patient 
was  kept  perfectly  quiet  in  a  recumbent  posture,  until 
the  fracture  united. 

After  remaining  in  the  Hospital  for  a  long  time,  he 
was  finally  discharged.  Dr.  Reynell  Coates,  who  was 
at  the  time  house-surgeon,  informs  me,  that  he  saw  this 
man  some  years  after  he  left  the  Hospital,  and  that  he 
had  recovered  sufficiently  to  move  about,  although  he 
was  still  lame. 


CONTUSIONS  OF  THE  BODY.  237 


CASE  XI. 

Fractured  Pelvis — Rupture  of  the  Urethra — Muscular 
Pouch  171  front  of  Bladder, 

9th  mo.  28th,  1818.  H.  O'C,  a  poor  labouring  man, 
was  brought  into  the  Pennsylvania  Hospital  under  the 
following  circumstances.  He  was  engaged  in  digging 
under  a  bank  of  earth  near  the  Schuylkill.  The  bank 
gave  way  above,  and  a  large  mass  of  earth  fell  upon 
him.  Some  workmen  in  the  neighbourhood  came  to  his 
assistance,  dug  him  out,  and  he  was  conveyed  to  the 
Hospital. 

When  I  saw  him,  he  complained  of  considerable  pain, 
principally  in  the  abdomen,  which  was  tumid,  and  ten- 
der on  pressure.  His  pulse  was  feeble,  and  his  skin  cool. 
I  directed  mild  nutritious  drinks,  with  opiates  to  allay 
pain,  intending  to  wait  for  reaction  of  the  system,  be- 
fore adopting  a  depletory  course. 

29th.  The  system  had  not  reacted.  The  abdomen 
was  very  much  swollen,  tense,  and  extremely  tender  to 
the  touch.  As  he  had  passed  no  urine  since  his  admis- 
sion. Dr.  B.  H.  Coates,  the  house-surgeon,  had  very  pro- 
perly introduced  a  catheter,  through  which  only  a  small 
portion  of  bloody  urine  had  escaped.  In  the  evening 
I  again  introduced  the  catheter;  it  passed  under  the 
arch  of  the  pubis,  but  a  small  portion  of  blood  and 
urine  escaped  as  before.  I  was  convinced  that  the  in- 
strument did  not  pass  as  far  as  it  usually  does,  when  it 
enters  the  bladder,  and  was  induced  to  believe  from  the 
symptoms,  that  the  viscus  was  ruptured.   Several  eva- 


238  RETENTION  FR03I  CONTUSIONS. 

cuations  from  the  bowels  were  produced  by  castor  oil, 
given  in  small  doses,  and  aided  by  an  enema.  But  the 
system  never  reacted. 

I  introduced  the  catheter  twice  after  this,  with  the 
same  result.  On  the  last  introduction  I  was  much  sur- 
prised to  perceive  bubbles  of  air  passing  out  through 
the  instrument.  The  patient  vomited  frequently  during 
his  short  illness;  and  died  about  midnight  on  the  1st  of 
10th  mo.,  being  the  fourth  day  after  the  accident. 

Dissection, 

10th  mo.  2d.  I  was  present  this  day,  when  Dr.  B.  H. 
Coates  examined  the  body. 

The  abdominal  muscles  below  the  umbilicus  were 
severely  contused,  being  black  with  effused  blood.  On 
opening  the  cavity  of  the  abomen,  the  stomach  and 
intestines  appeared  healthy,  but  enormously  distended 
with  flatus. 

The  left  os  pubis  was  fractured,  and  the  fractured 
portions  separated  from  each  other  for  some  distance, 
so  that  three  fingers  might  be  passed  between  the  op- 
posing surfaces.  In  consequence  of  the  extent  of  this 
fracture,  the  soft  parts  in  the  vicinity  were  very  much 
lacerated.  The  posterior  portion  of  the  urethra,  under 
the  arch  of  the  pubis,  had  been  ruptured,  and  contained 
an  opening  nearly  large  enough  to  admit  the  finger. 
Through  this  aperture  the  urine  had  escaped,  and  mix- 
ing with  the  efiused  blood,  had  distended  the  lacerated 
parts  anterior  to  the  bladder  and  peritoneum;  forming 
at  this  part  a  large  pouch,  like  another  bladder  in  front 
of  the  true  one.  In  consequence  of  its  free  passage  in 
this  direction,  the  urine  had  not  been  infiltrated  into  the 
cellular  tissue,  about  the  perineum  and  scrotum,  as  ex- 


RUPTURE  OP  THE  BLADDER  FROM  CONTUSION,  &C.  239 

tensively  as  it  generally  is  in  cases  of  ruptured  ure- 
thra. The  muscular  structure  lining  the  pouch  was  of  a 
dark  colour,  resembling  gangrene. 

In  this  case,  I  believe  the  catheter  never  reached  the 
bladder,  but  passed  through  the  aperture  in  the  urethra, 
and  entered  the  pouch  in  front  of  that  organ. 


SECTION  V. 


RUPTURE  OF  THE  BLADDER  FROM  CONTUSION  OF  THE  ABDOMEN. 

When  the  bladder  is  in  a  state  of  distension,  the 
application  of  external  force  may  have  the  effect  of 
rupturing  the  organ.  This  is  a  very  rare  accident;  one 
case  has  fallen  under  my  observation,  which  I  will 
briefly  narrate. 


CASE  XII. 

Rupture  of  the  Bladder — Death. 

A  poor  blind  man  was  brought  into  the  Almshouse 
hospital,  under  the  following  circumstances: 

He  slept  in  the  third  story  of  a  house,  built  for  a 
store,  in  which  a  door  opened  toward  the  yard  below. 
He  rose  in  the  night  for  the  purpose  of  voiding  his 
urine,  the  bladder  of  course  being  distended.  In  at- 
tempting to  find  the  window,  he  fell  against  the  door, 
which  opened,  and  he  was  precipitated  into  the  yard. 


240  RUPTURE  OF  THE  BLADDER 

He  fell  with  the  abdomen  across  a  fence,  and  to  use 
his  own  simple  language,  "  his  belly  struck  first."  He 
was  taken  up,  and  was  conveyed  next  morning  to  the 
Almshouse. 

I  saw  him  soon  after  his  admission.  The  abdomen 
was  tumid  and  tense,  leading  me,  in  the  first  instance, 
to  infer  distension  of  the  bladder.  He  had  passed  no 
urine  since  the  accident.  On  introducing  a  catheter,  a 
considerable  quantity  of  blood  mixed  with  urine,  flowed 
through  the  instrument.  But  the  tension  and  uneasiness 
increased;  he  complained  of  severe  pain  in  the  abdo- 
men, and  in  about  thirty  hours  after  the  injury,  he  died. 

Dissection. 
The  fundus  of  the  bladder  was  ruptured — urine  had 
escaped  into  the  cavity  of  the  abdomen,  producing  ex- 
tensive peritoneal  inflammation. 

An  account  of  a  case  of  ruptured  bladder,  under 
the  care  of  my  friend  Dr.  George  Uhler  of  this  city, 
was  drawn  up  by  him,  at  my  request,  eighteen  montHs 
after  its  occurrence. 

It  exhibits  a  highly  interesting  example  of  lesion  of 
the  bladder,  from  external  violence,  which  resulted  in  a 
complete  solution  of  continuity  in  the  injured  part,  and 
an  eflfusion  of  urine  into  the  cavity  of  the  peritoneum, 
terminating  in  the  death  of  the  patient. 


CASE  xin. 

Contusion  of  the  Bladder — Lesion  of  the  Fundus, 

Dr.  Uhler  was  called  to  the  patient  in  the  morning, 
and  received  the  following  history  of  the  case.  On  the 


PROM  CONTUSION  OF  THE  ABDOMEN.       241 

previous  evening,  the  poor  man  had  eaten  very  freely 
of  water-melon,  after  which  he  was  romping  near  his 
door  with  some  of  his  young  neighbours,  when  he  acci- 
dentally ran  against  a  post,  and  received  a  severe  blow 
upon  the  lower  part  of  his  abdomen.  The  pain  at  the 
moment  was  very  considerable,  but  subsided  in  a  short 
time. 

When  Dr.  Uhler  saw  the  patient  the  next  day,  his 
chief  uneasiness  was  attributed  to  retention  of  urine,  as 
he  had  discharged  no  urine  since  the  previous  after- 
noon. Tlie  case  did  not  appear  very  urgent,  as  the 
patient  was  walking  about  his  house,  and  the  Doctor 
merely  advised  him  to  take  some  diuretic  medicine. 
On  visitino;  him  in  the  eveninsj  the  retention  continued, 
and  the  abdomen  was  much  distended.  The  Doctor 
now  suspected  the  nature  of  the  injury,  introduced  a 
catheter,  and  drew  off  four  and  a  half  pints  of  urine  of 
a  natural  appearance.  As  the  urine  flowed,  the  tume- 
faction of  the  abdomen  diminished,  and  the  patient 
appeared  to  be  entirely  relieved  by  the  operation.  He 
walked  out  to  see  a  neighbour,  and  appeared  free  from 
suffering  or  disease. 

In  a  few  hours  afterward  he  was  suddenly  attacked 
with  symptoms  of  peritoneal  inflammation,  which  con- 
tinued for  several  days,  when  he  died. 

The  body  was  examined  by  Dr.  Uhler.  An  opening 
lartre  enou";h  to  admit  three  fiuijers  was  found  in  the 
fundus  of  the  bladder.  The  peritoneum  exhibited  evi- 
dences of  hiijh  and  general  inflammation,  from  the 
effusion  of  urine. 

Remark, 

Should  a  case  of  this  kind  fall  under  my  observation, 
I  would  introduce  a  small  flexible  catheter,  and  allow 
31 


242  RETENTION  FROM  CONTUSION  OF  THE 

it  to  remain  constantly  in  the  bladder,  in  order  to  keep 
the  visciis  entirely  at  rest,  and  to  favour  a  contrac- 
tion of  its  muscular  fibres.  By  this  means  the  sides  of 
the  organ  would  be  approximated,  and  the  efforts  of 
nature  to  repair  the  injury  would  be  promoted. 


SECTION  VI. 


RETENTION  OF  URINE  FROM  CONTUSION  OF  THE  PERINEUM 

TAPPING  THE  BLADDER. 

So  far  as  my  observation  has  extended,  accidents  of 
this  kind  are  very  rare.  When  they  do  occur,  they  are 
generally  very  serious  in  their  character. 

The  direct  application  of  force  to  the  perineum  is 
followed  by  tumefaction  of  the  parts,  arising  from  the 
effusion  of  blood,  and  subsequent  inflammation.  Such 
a  condition  cannot  take  place  without  involving  the 
urethra  in  its  consequences.  The  size  of  the  canal  is 
frequently  very  much  diminished,  and  great  difficulty 
is  experienced  by  the  patient  in  evacuating  his  urine. 
So  long,  however,  as  he  is  capable  of  discharging  urine, 
even  though  the  effort  is  attended  with  great  pain,  the 
danger  is  comparatively  slight. 

When  the  obstruction  becomes  complete,  his  life  is 
put  at  hazard  unless  relief  is  obtained  by  proper  means. 
While  the  integrity  of  the  urinal  canal  is  maintained, 
ultimate  restoration,  without  the  necessity  of  tapping 
the  bladder,  may  still  be  anticipated. 

If  the  violence  of  the  injury  should  have  been  suffi- 
cient to  lacerate  the  urethra,  and  the  passage  of  a  ca- 


PERINEUM. TAPPING  THE  BLADDER.  243 

tlieter  into  the  bladder  is  impossible,  the  only  alterna- 
tive which  is  presented  to  the  surgeon,  is  to  form  an 
artificial  outlet  for  the  urine  by  an  operation. 

Two  situations  have  been  proposed  by  surgeons,  for 
the  performance  of  this  operation.  Some  recommend 
that  the  puncture  should  be  made  through  the  rectum, 
while  others  prefer  the  operation  above  the  pubis. 

I  liave  never  seen  the  bladder  tapped  but  once,  and 
then  I  was  the  operator.  The  case  will  be  fully  de- 
tailed, in  order  to  exhibit  the  difficulties  of  the  opera- 
tion by  the  rectum,  at  least  in  this  class  of  accidents; 
and  to  present  the  reasons  why,  with  my  present  limited 
experience,  I  should  prefer  the  operation  above  the 
pubis. 


CASE  XIV. 


Contusion  of  the  Perineum — Retention  of  Urine  from 

effusion  of  Lymph, 

In  the  winter  of  1820,  a  patient  was  admitted  into 
the  surgical  ward  of  the  Almshouse  Infirmary,  under 
the  followinsf  circumstances: 

He  had  fallen  into  a  tanner's  vat,  and  had  sustained 
a  severe  contusion  of  the  perineum  and  the  parts  adja- 
cent. The  scrotum  and  penis  were  much  swollen.  In 
the  latter  there  was  great  effiision,  so  as  to  cause  a 
very  troublesome  phymosis.  I  was  obliged  to  treat  this 
by  a  number  of  small  punctures  with  a  keen  lancet, 
tln-ough  which  a  serous  fluid  was  discharged.  The 
patient  passed  his  urine  with  very  considerable  diffi- 


244       RETENTION  FROM  CONTUSION  OF  THE 

culty.  I  placed  him  under  an  antiphlogistic  plan  of  treat- 
ment. Although  the  inflammatory  symptoms  subsided, 
yet  the  stream  of  urine  gradually  diminished  in  size. 
A  small  bougie  or  catheter  could  not  be  passed,  and  it 
was  with  great  difficulty  the  bladder  could  be  relieved. 
I  supposed  this  to  be  the  consequence  of  preceding  in- 
flammation, and  that  an  eflfusion  of  lymph  had  dimi- 
nished the  diameter  of  the  urethra.  With  a  view  to 
promote  the  absorption  of  this  lymph,  I  ordered  the 
camphorated  mercurial  ointment  to  be  rubbed  freely 
and  frequently  on  the  perineum.  This  plan  was  per- 
sisted in  for  some  time,  combined  with  the  use  of  the 
warm  bath.  The  patient  became  worse  and  worse,  until 
at  last  his  strongest  efforts  were  insufficient  to  evacuate 
the  bladder,  which  became  considerably  distended.  In 
this  dilemma  I  was  afraid  we  should  have  to  resort  to 
some  serious  operation.  I  endeavoured  to  introduce 
a  very  small  catheter  without  success.  Having  proved 
in  some  instances  the  efficacy  of  large  catheters  after 
failure  with  small  ones,  I  introduced  a  flexible  catheter 
of  very  large  size,  with  a  stilet,  and  passed  it  down 
to  the  obstruction,  pressing  it  with  moderate  force 
against  the  part.  In  a  little  while  I  felt  something  to 
give  way,  or  rather  to  tear.  The  catheter  then  ad- 
vanced. Directly  afterwards  another  obstruction  was 
encountered  by  the  instrument,  but  it  yielded  more 
readily  than  the  first.  Then,  to  my  great  joy,  the  ca- 
theter entered  the  bladder,  and  the  urine  flowed  freely. 


In  this  case  there  was  evidently  an  adhesion  between 
the  sides  of  the  urethra,  producing  an  almost  total  ob- 
literation of  the  canal.  The  large  catheter,  by  distend- 
ing the  urethra,  rent  asunder  the  new-formed  parts. 


PERINEUM. TAPPING    THE  BLADDER.  245 

One  thing  occurred  in  this  case  which  was  remark- 
able.  When  the  urine  began  to  flow,  instead  of  the  ex- 
quisite relief  usually  experienced  by  the  use  of  the 
catheter,  the  patient  was  seized  with  severe  pain  and 
spasms,  attended  by  strong  retraction  of  testes.  He 
really  seemed  in  an  agony,  and  begged  to  have  the 
catheter  withdrawn.  He  rose  from  his  bed  and  requested 
to  be  allowed  to  stand  erect.  I  was  obliged  to  give  him 
sixty  drops  of  laudanum,  but  did  not  immediately  with- 
draw the  catheter. 

My  last  note  of  this  case  is  dated  several  weeks 
after  the  introduction  of  the  catheter,  and  ends  with 
this  information: — The  patient  is  still  in  the  hospital; 
his  condition  much  improved.  I  think  he  may  soon  be 
discharged  cured. 


CASE  XV. 

Kctention  of  Urine  from  Contusion  of  the  Perineum — Tap- 
ping the  Bladder. 

lOth  mo.  15th,  1828.  Jeremiah  Waterhousc,  aged 
about  thirty-five  years,  farmer,  a  muscular,  strong,  and 
admirably  well-formed  Englishman,  was  admitted  into 
the  Pennsylvania  Hospital  with  a  severe  injury  of  the 
perineum  and  scrotum.  The  accident  occurred  in  the  fol- 
lowing manner: — The  patient  Mas  in  the  service  of  Geo. 
Bleight,  at  his  farm  near  Germantown.  While  in  the 
city  with  a  farm  wagon  and  horses,  he  was  standing  on 
the  shelvings  of  the  wagon,  when  the  horses  started  off- 
he  was  thrown  from  his  position  and  fell  astride  and  in 


246  RETENTION  FROM  CONTUSION  OF  THE 

front  of  one  of  tlie  wheels,  which  struck  him  witli  great 
force  on  the  perineum.  After  the  accident  he  was  car- 
ried home,  and  was  visited  by  Dr.  Betton,  of  German- 
town,  who  advised  his  removal  to  the  Hospital. 

Dr.  J.  Rhea  Barton,  the  attending  surgeon  at  that 
time  being  absent  from  the  city,  1  w  as  called  to  visit 
the  patient,  and  saw  him  about  twenty-four  hours  after 
the  injury  was  received. 

I  found  him  in  great  pain;  his  bladder  was  much  dis- 
tended, and  he  w^as  entirely  unable  to  pass  urine.  The 
introduction  of  the  catheter  had  been  several  times 
attempted  before  I  visited  him  by  Dr.  George  Fox,  the 
house  surgeon.  He  found  it  impossible  to  succeed. 
The  situation  of  the  poor  sufferer  was  sufficient  to  kin- 
dle up  the  sympathy  of  any  one  that  saw  him.  His 
distress  was  intense,  yet  he  bore  it  w  ith  manly  fortitude. 
I  put  forth  my  best  endeavours  to  relieve  him.  Re- 
peated attempts  were  made  to  introduce  the  catheter 
with  all  possible  gentleness.  Every  effort  was  unavail- 
ing. I  left  him  after  directing  that  he  should  be  freely 
bled,  and  have  leeches  applied  to  the  perineum,  in  order, 
if  possible,  to  reduce  the  inflammation  and  tumefaction 
of  the  parts.  An  opiate  was  prescribed.  On  my  return 
again  that  night,  the  attempt  to  pass  the  catheter  was 
renewed,  with  the  same  result.  At  this  visit  my  fears 
were  fully  confirmed,  that  the  urethra  was  extensively 
lacerated.  I  ordered  a  consultation  to  be  called  next 
morning,  and  left  the  patient,  after  directing  that  he 
should  be  kept  quiet  by  opiates. 

My  colleague.  Dr.  Thomas  T.  Hewson,  met  me  at 
10  o'clock.  We  found  the  patient  in  great  pain,  and 
very  anxious  for  relief.     The  catheter  could  not  be  in- 


PERINEUM. TAPPING  THE  BLADDER.  247 

troduced,  and  we  concluded  to  tap  the  bladder  from  the 
rectum. 

When  about  to  proceed  to  the  operation,  I  intro- 
duced my  finger  into  the  rectum,  and  was  forcibly 
struck  with  the  absence  of  that  elastic  feeling  imparted 
to  the  finger  in  a  common  case  of  distended  bladder. 
Instead  of  this,  it  gave  the  sensation  of  a  soft,  doughy 
substance,  as  if  the  indentation  of  the  finger  must  have 
remained  sometime  after  it  was  withdrawn  from  the 
part.  I  requested  my  friend  Dr.  Hew  son  to  examine,  and 
his  impressions  were  precisely  the  same.  We  concluded 
that  this  state  of  things  must  be  caused  by  an  effusion 
of  blood  between  the  rectum  and  bladder.  We  thought 
it  best  to  proceed  with  the  curved  trochar,  as  the  au- 
thority of  surgeons,  perhaps,  preponderated  in  favour 
of  a  puncture  from  the  rectum  in  case  of  recent  acci- 
dent. I  now  introduced  the  instrument,  and  pushed  it 
through  the  rectum  towards  the  bladder  so  far  as  ap- 
peared necessary  to  reach  the  viscus.  On  withdrawing 
the  stilet,  nothing  but  a  little  grumous  blood  passed 
through  the  canula.  We  were  placed  in  a  painful  di- 
lemma. To  fail  in  relieving  a  fellow  creature  from  ex- 
treme suffering  was  distressing,  and  we  could  not  avoid 
feeling  increased  interest  in  the  patient,  from  the  entire 
confidence  he  reposed  in  us,  and  the  readiness  with 
which  he  submitted  to  every  thing  we  proposed. 

It  was  now  agreed  to  make  a  puncture  a  little  higher 
up,  which  was  done,  and  the  instrument  was  pushed  as 
far  towards  the  bladder  as  we  thought  prudent.  It  re- 
sulted in  bitter  disappointment;  no  urine  passed  through 
it.  Xo  doubt  now  remained  of  a  much  more  extensive 
effusion  of  blood  between  the  rectum  and  bladder  than 
we  had  anticii)ated.     We  met  again  at  3  o'clock,  and 


248       RETENTION  FROM  CONTUSION  OF  THE 

Drs.  Physick  and  Hartshorne,  two  of  the  former  sur- 
geons of  the  institution  were  invited,  and  kindly  at- 
tended. The  whole  case  was  laid  fully  before  them; 
they  made  one  more  unavailing  effort  to  pass  the  ca- 
theter, and  we  all  united  in  judgment  that  the  only 
alternative  which  remained,  was  to  tap  the  bladder 
above  the  pubis.  The  patient  was  not  only  willing,  but 
desirous  of  having  the  operation  performed. 

Assisted  by  my  friends  Drs.  Physick,  Hewson,  and 
Hartshorne,  and  in  the  presence  of  a  number  of  pupils, 
I  proceeded,  and  made  an  incision  in  the  course  of  the 
linea  alba  a  little  above  the  pubis,  the  parts  being  pre- 
viously shaved.  I  carefully  dissected  down  between  the 
pyramidal  muscles,  and  soon  felt  the  distended  bladder. 
I  now  passed  a  curved  trochar  down  into  the  viscus. 
The  stilet  was  withdrawn,  and  the  urine  followed.  I  had 
prepared  for  the  occasion  a  second  silver  canula,  with 
a  rounded  point,  and  perforated  with  holes  on  the  side 
like  the  common  catheter.  This  was  accurately  adapted 
to  the  large  canula,  so  that  it  could  be  passed  through 
it  into  the  bladder.  This  was  done,  and  the  bladder  was 
relieved  by  a  copious  discharge  of  urine.  The  advan- 
tage of  this  second  canula  consisted  in  its  projecting 
some  distance  beyond  the  other,  and  presenting  to  the 
internal  coat  of  the  bladder,  a  smooth  rounded  surface, 
instead  of  an  abrupt  edge.  The  canulae  were  now  re- 
tained in  the  bladder  by  means  of  tapes,  and  the  wound 
was  closed  by  adhesive  strips. 

After  the  operation  the  patient  was  kept  under  the 
use  of  opiates,  and,  for  the  first  few  days,  upon  a  low 
diet.  He  had  but  little  fever,  and  passed  his  urine  freely 
through  the  canula;  though  with  all  the  care  that  could 
be  taken,  some   portion  would  escape   through   the 


TAPPING  THE  BLADDER.  249 

wound  by  the  side  of  the  instrument.  The  afflictions  of 
the  patient  did  not  terminate  here.  His  scrotum  be- 
came more  tumid,  and  exhibited  evident  marks  of  gan- 
grene. He  was  now  placed  on  a  very  generous  diet, 
with  bark,  ehxir  of  vitriol,  6lc.  Poultices  were  applied 
to  the  mortified  parts.  Dr.  Barton  having  returned,  the 
patient  was  placed  under  his  care.  A  flexible  catheter 
was  finally  substituted  for  the  silver  canulse;  the  mor- 
tified parts  about  the  scrotum  sloughed  and  healed; 
but  his  constitution  had  received  a  shock  too  severe  for 
his  ultimate  restoration.  As  he  weakened,  a  most  ex- 
tensive slough  took  place  on  his  back,  and  he  finally 
died  with  hectic  fever,  11 /A  mo.  16th,  about  one  month 
after  the  accident.  On  dissection  after  death,  it  was 
ascertained  that  the  two  punctures  made  through  the 
rectum  had  entirely  healed. 


The  evidences  presented  on  dissection  in  this  case, 
afforded  to  my  mind  the  gratifying  assurance,  that  the 
poor  sufferer  did  not  sustain  any  material  injury  from 
the  unsuccessful  efforts  to  puncture  the  bladder  from 
the  rectum. 

It  has  settled  me,  however,  in  the  conclusion,  that  un- 
til more  enlarged  opportunities  for  judging  on  this  sub- 
ject shall  be  afforded,  I  shall  never  again  attempt  to 
tap  the  bladder  from  the  rectum.  The  opinion  of  my 
worthy  old  master,  Dr.Wistar,  was  decidedly  in  favour 
of  the  operation  above  the  pubis;  and  it  will  require 
some  pretty  clear  evidence  to  change  my  present  opi- 
nion. 

32 


250  RETENTION  FROM 


SECTION  VII. 


RETENTION  FROM  DISEASED  PROSTATE. 

Among  the  diseases  peculiar  to  advanced  life,  is  an 
enlarged  condition  of  the  prostate  gland.  This  gland 
is  situated  at  the  neck  of  the  urinary  bladder,  and  is 
called  into  action  in  every  effort  to  evacuate  its  con- 
tents. 

The  morbid  condition  of  this  structure  which  we  are 
about  to  notice,  first  manifests  itself  by  a  frequent  de- 
sire to  void  urine,  obliging  the  patient  to  rise  several 
times  in  the  course  of  the  night.  This  disposition  slowly 
increases,  until  the  calls  become  very  frequent,  accom- 
panied with  severe  pain  and  straining.  As  the  disease 
advances,  retention  of  urine  to  a  greater  or  less  ex- 
tent, not  unfrequently  takes  place,  requiring  the  use  of 
the  catheter. 

In  some  constitutions,  the  inroads  of  the  disease  are 
gradual,  and  several  years  may  elapse,  without  any 
evidence  of  immediate  danger,  and  the  symptoms  are 
regarded  rather  as  a  source  of  inconvenience,  than  of 
positive  suffering.  The  aged  subject  may  be  kindly  per- 
mitted to  pass  out  of  life  with  some  more  acute  disease, 
thus  escaping  a  protracted  death  from  pain  and  con- 
stitutional irritation. 

When  the  complaint  assumes  its  most  aggravated 
form,  the  sufferings  of  the  patient  become  intense.  The 
bladder  is  excessively  irritable,  and  incapable  of  retain- 
ing even  a  small  portion  of  urine,  without  producing 
great  distress.     I  have  known  a  patient  in  this  condi- 


DISEASED  PROSTATE.  251 

tion  to  be  compelled  to  rise  tJiirly  times  in  the  course 
of  the  night,  making  at  each  attempt  strong  efforts  to 
discharge  a  very  small  portion  of  urine. 

As  the  disease  advances,  the  energies  of  the  system 
are  gradually  exhausted.  Emaciation,  debility,  hectic 
fever,  and  death  are  the  result. 

A  post  mortem  examination  reveals  the  cause  of  the 
symptoms  just  described.  The  prostate  gland,  which  in 
a  natural  state  does  not  exceed  the  size  of  a  horse-ches- 
nut,  may  be  found  equal  in  bulk  to  a  large  pear.  Some- 
times the  enlargement  is  most  conspicuous  in  the  late- 
ral lobes,  while  in  other  instances  the  third  lobe  seems 
to  have  been  principally  affected.  The  latter  form  is 
the  more  serious,  from  the  fact  of  this  lobe  forming,  in 
a  natural  state,  a  small  projection  towards  the  urethra, 
which,  when  increased  by  disease,  constitutes  a  large 
triangular  body,  overhanging  the  opening  of  the  ure- 
thra into  the  bladder.  This  lobe  acts  the  part  of  a 
valve,  which,  under  certain  morbid  conditions,  may 
completely  close  the  opening  from  the  bladder  into  the 
urethra;  offering  a  most  serious  mechanical  impedi- 
ment to  the  introduction  of  the  catheter,  which  will  be 
noticed  in  its  proper  place.  From  the  peculiar  position 
of  the  valve  it  must  be  evident,  that  in  every  effort  to 
expel  the  contents  of  the  bladder,  it  is  pressed  more 
firmly  over  the  opening,  and  the  obstruction  is  ren- 
dered more  complete.  See  PI.  1  and  2. 

Another  striking  post  mortem  appearance,  as  ex- 
hibited in  the  drawings,  is  the  thickened  and  rough  sur- 
face of  the  inner  coats  of  the  bladder.  The  eye  is  ar- 
rested w^ith  a  great  number  of  strong  bands  of  diflcrent 
dimensions,  and  variously  distributed,  resembling  very 
closely  the  musculi  pectinati  of  the  heart.  See  PI.  .3. 


252  TREATMENT  OF 

These  appearances  are  produced  by  an  enlargement 
of  the  muscular  fibres  of  the  bladder.  It  has  been 
supposed  by  some  writers,  that  this  condition  of  the 
parts  was  produced  by  the  chronic  inflammation  of 
the  mucous  membrane,  communicated  to  the  muscular 
coat.  I  am  disposed  to  refer  them  to  another  cause. 
I  believe  that  this  extraordinary  development  of  mus- 
cular fibre  depends  upon  the  frequent  and  violent  con- 
tractions of  the  organ,  which  are  inseparable  from  this 
distressing  malady. 

Its  explanation  may  be  referred  to  the  same  law 
which  regulates  the  size  and  development  of  muscles, 
which  are  subjected  to  unusual  exercise  in  other  parts 
of  the  body.  Who  has  not  admired,  in  passing  along 
our  streets,  the  powerful  flexors  and  extensors  in  the 
arms  of  some  of  ourwoodsawyers,or  the  swelling  deltoid 
of  the  blacksmith  accustomed  to  the  daily  use  of  the 
sledgehammer.  This  same  view  might  be  extended  to  a 
variety  of  muscles,  more  particularly  connected  with 
various  mechanical  operations. 

Between  the  bands  formed  by  this  thickened  muscu- 
lar fibre,  it  is  not  uncommon  to  observe  pouches  of 
various  dimensions,  in  which  calculi  are  sometimes 
deposited.  As  the  bands  enlarge,  the  stone  is  firmly 
bound  down, and  may  become  completely  encysted,  thus 
naturally  causing  a  cessation  of  the  symptoms. 


SECTION  VIII. 


TREATMENT  OF  ENLARGED  PROSTATE. 

It  would  be  a  source  of  extreme  gratification  could 


ENLARGED  PROSTATE.  253 

we  offer  the  cheering  prospect  of  radical  cure,  in  this 
distressing  malady. 

A  great  variety  of  remedies  have  been  recommended; 
but  as  far  as  my  knowledge  extends,  they  can  rise  no 
higher  in  the  scale  than  mere  palliatives.  To  relieve 
the  violent  pain  attendant  on  the  disease,  we  must 
chiefly  rely  on  opiates,  particularly  on  anodyne  injec- 
tions. Emollient  drinks,  the  warm  bath,  and  sometimes, 
under  particular  circumstances,  general  and  topical 
bleeding  may  be  required. 

The  frequent  use  of  the  flexible  gum  elastic  catheter 
is  generally  demanded,  and  the  patient  should  be  in- 
structed to  introduce  it  for  himself 

I  regard  it  as  important  in  this  disease,  which,  from 
its  intractable  character,  and  the  advanced  age  of  the 
patient,  precludes  the  hope  of  a  radical  cure,  that  we 
should  adopt  such  palliative  measures  as  will  promote 
the  tone  both  of  the  body  and  mind.  Hence  moderate 
exercise  in  the  fresh  air,  and  employment  of  the  mind 
on  passing  objects,  is  greatly  to  be  preferred  to  con- 
stant confinement  within  the  narrow  precints  of  a  sick 
chamber. 

In  the  more  advanced  stages  of  the  disease,  when  the 
patient  is  necessarily  confined  to  bed,  the  obstruction 
may  be  so  great  as  to  render  the  passage  of  the  cathe- 
ter difficult.  In  these  cases  the  constant  wearing  of  the 
instrument  becomes  necessary. 

I  have  recently  met  with  a  suggestion  in  regard  to 
the  treatment  of  enlarged  prostate,  emanating  from  a 
source  which  entitles  it  to  high  respect.  It  is  compre- 
hended in  the  following  extract  from  G.  J.  Guthrie  on 
Diseases  of  the  Urinary  Organs. 

"  A  question  has  arisen  in  my  mind,  whether  any 


254  TREATMENT  OP 

operation  could  be  done  on  the  prostate  from  the  peri- 
neum; and  I  was  led  to  entertain  it,  from  finding,  that 
in  a  patient  upon  whom  I  had  operated  for  stone,  whose 
prostate  gland  was  much  enlarged,  I  had  rendered  him 
a  further  service  in  the  diminution  of  the  prostate;  so 
that  instead  of  making  his  water  with  difficulty,  he 
afterwards  made  it  easily,  and  the  catheter  passed  with 
facility,  instead  of  meeting  with  a  considerable  obsta- 
cle at  the  neck  of  the  bladder.  In  fact,  I  was  satisfied 
I  had  cured,  or  nearly  so,  the  disease  of  the  left  lobe  of 
the  prostate,  which  I  found  to  be  much  enlarged  during 
the  operation." 

To  strengthen  this  suggestion,  the  author  refers  to 
some  observations  of  W.  Blizard,  read  before  the  Me- 
dico-Chirurgical  Society,  by  which  it  appears  that  he 
had  several  times  divided  the  prostate  when  in  an  en- 
larged condition,  though  not  in  a  state  of  inflammation. 
The  condition  referred  to,  is  thus  described  in  his  own 
language:  "  When  the  inflammation  ceases,  the  puru- 
lent matter  may  remain  confined  by  the ^rm  investmefit 
of  the  prostate  gland  for  a  length  of  time,  according  to 
various  circumstances." 

This  condition  does  not  present  to  my  mind  any 
confirmation  of  the  opinion  of  G.  J-.  Guthrie.  In  the 
cases  operated  upon  by  Blizard,  the  inflammation  had 
ceased,  and  the  object  of  the  operation  was  to  give 
exit  to  confined  pus.  I  have  never  seen  such  an 
operation,  and  though  I  should  be  cautious  about  per- 
forming it  myself,  I  would  not  attempt  to  oppose 
theoretical  views  to  experience  from  such  a  source.  I 
have  in  my  own  practice,  at  this  time,  an  elderly  gen- 
tleman, with  diseased  prostate,  requiring  the  frequent 
use  of  the  catheter,  and  on  two  occasions  nature  ap- 
pears to  have  relieved  him,  by  the  free  discharge  of 


ENLARGED  PROSTATE.  255 

purulent  matter  from  the  penis,  which  I  have  supposed 
camo  from  an  abscess  in  the  prostate  gland.  This  dis- 
charge, after  continuing  for  some  time,  has  on  both 
occasions  abated,  and  finally  ceased.  The  patient  is 
enabled  to  keep  about,  and  uses  moderate  exertion  in 
business. 

The  proposition  to  lay  open  the  prostate  from  the 
perineum,  in  ordinary  cases,  demands  serious  consi- 
deration. Should  experience  confirm  the  propriety  of 
this  practice,  it  would  open  a  cheering  prospect  to 
many  aged  patients,  who  are  doomed  to  pass  their  few 
remaining  days  in  suffering  and  sorrow.  An  enlarged 
state  of  the  prostate,  instead  of  being  a  serious  objec- 
tion to  the  operation  for  lithotomy,  w  ould,  under  this 
view,  rather  invite  it,  with  a  hope,  that  in  addition  to 
the  removal  of  calculus  from  the  bladder,  the  prostate 
might  be  radically  cured. 

I  am  free  to  confess  with  diffidence,  that  an  incision 
into  a  part  enlarged  by  chronic  inflammation,  for  the 
purpose  of  radical  cure,  is  not  in  accordance  with  my 
views  of  sound  surgical  practice. 

We  must  look  to  the  experience  of  lithotomists, 
either  to  sustain  or  reject  this  suggestion.  In  order  to 
be  decisive,  a  post  mortem  examination  should  be  made 
in  every  instance,  to  ascertain  whether  the  gland  is 
actually  diminished  in  size.  Removal  of  pain,  and  even 
a  restoration  to  tolerable  health,  after  the  operation  for 
stone,  cannot  be  accepted  as  evidence  of  material  di- 
minution in  the  size  of  the  prostate.  The  gland  may 
be  increased  in  size  without  producing  of  itself  much 
suffering  to  the  patient;  while  the  additional  irritation 
of  a  calculus  in  the  bladder  may  cause  intense  pain. 
Under  these  circumstances,  the  removal  of  the  calculus 


256  TREATMENT  OF 

would  render  the  patient  comparatively  very  comfort- 
able, without,  at  the  same  time,  producing  any  other 
effect  upon  the  prostate,  that  to  relieve  it  from  the  irri- 
tation of  a  foreign  substance  situated  in  its  immediate 
vicinity. 

Although  my  own  experience  does  not  furnish  a  case 
of  stone  complicated  with  enlarged  prostate,  in  which 
an  operation  was  performed,  yet  a  striking  instance 
has  lately  occurred  in  this  city,  in  the  person  of  the  late 
Chief  Justice  Marshall.  This  highly  distinguished  and 
excellent  man,  was  subjected  to  the  operation  of  litho- 
tomy by  Dr.  Physick,  and  a  large  number  of  calculi 
were  removed  from  the  bladder.  The  prostate  gland 
was  considerably  enlarged  at  the  time  of  the  operation, 
and  the  third  lobe  was  distinctly  felt  projecting  into  the 
bladder. 

The  venerable  patient  recovered  most  happily,  re- 
sumed his  official  duties,  and  enjoyed  a  considerable 
share  of  health  for  several  years.  He  died  with  a  dis- 
ease unconnected  with  the  urinary  organs.  A  post 
mortem  examination  was  made,  and  the  prostate  parti- 
cularly examined.  Dr.  Physick,  (whose  opinion  on  this 
point  was  requested,)  explicitly  states,  that  the  size  of 
the  gland  was  not  diminished  by  the  operation.  The 
preparation  is  now  in  his  possession. 

Here  we  are  presented  with  opposite  experience,  de- 
rived in  both  instances  from  a  very  high  source.  The 
proposition  may,  however,  be  still  further  examined. 
Admitting  that  an  incision  into  the  prostate  will  pro- 
duce a  salutary  effect,  is  it  not  possible,  when  this  gland 
becomes  enlarged,  that  its  firm  investment  by  the  mem- 
brane mentioned  by  W.  Blizard,  may  act  on  the  same 
principle  as  the  thecae  of  the  fingers  in  paronychia,  or 


ENLARGED  PROSTATE.  257 

the  thick  skin  which  covers  the  fingers  of  labouring 
men  in  that  disease.  Where  is  the  surgeon  who  has  not 
been  called  upon  by  hard-working  men  in  extreme  pain 
in  the  early  stage  of  felon,  before  the  formation  of  pus? 
He  understands  in  a  moment  that  the  skin  in  these 
cases,  acts  like  a  bandage  drawn  firmly  over  an  in- 
flamed part;  and  that  the  primary  indication  for  relief, 
as  well  as  cure,  consists  in  laying  open  the  tumid  finger, 
and,  by  a  free  incision  through  the  skin,  thus  removing 
the  stricture. 

The  effect  of  an  artificial  bandage  on  an  inflamed 
limb,  is  familiar  to  every  experienced  practitioner. 
Who  has  not  seen  patients  brought  into  a  hospital  ward, 
a  few  days  after  receiving  a  fracture,  with  the  limb 
firmly  bound  by  a  roller.  The  patient  suffering  great 
pain,  and  the  parts  rapidly  verging  on  towards  gan- 
grene? 

These  illustrations  include  inflammation  in  an  acute 
form;  but  it  is  easy  to  apply  the  same  reasoning  to 
morbid  changes  in  structure,  of  a  chronic  character,  and 
thus  "  the  firm  investing  membrane  of  the  prostate 
gland"  may  produce  results  somewhat  analogous  to  the 
thecae  and  thickened  skin  in  paronychia.  Hence  it  may 
be  supposed,  that  a  division  of  the  investing  membrane 
of  the  prostate  may  produce  a  salutary  effect. 

After  reviewing  the  arojuments  in  favour  and  against 
the  suggestion  of  G.  J.  Guthrie,  in  the  absence  of  suffi- 
cient experience  on  the  subject.  I  would  modestly  ven- 
ture to  say,  that  the  division  of  the  prostate  would  be 
hazardous  and  improper.  It  must  be  recollected,  that 
this  disease  makes  its  appearance  in  individuals  ad- 
vanced in  years,  whose  constitutional  energies  are 
nearly  exhausted,  and  that  a  severe  operation  of  the 


258  TREATMENT  OF 

kind  proposed,  might  sink  the  system  below  the  point 
of  reaction. 

It  may  be  remarked  also,  in  connection  with  this 
subject,  that  wounds  of  the  prostate  sometimes  result 
very  inconveniently.  Dr.  Physick  states  a  case,  which 
fell  under  his  notice,  of  a  man  whose  prostate  had  been 
pierced  by  attempts  to  introduce  the  catheter,  in  un- 
skilful hands.  He  recovered  from  the  wound,  regained 
his  health,  and  lived  for  several  years;  during  the  whole 
of  which  time  he  was  afflicted  with  incontinence  of 
urine. 

One  of  the  most  important  means  of  relief  in  this 
distressing  malady,  consists  in  the  dilatation  of  the 
passage  through  the  prostate  gland.  A  plan  of  dilating 
the  urethra,  by  injecting  fluid  through  a  catheter,  to  the 
extremity  of  which  a  thin  bag  is  attached,  was  intro- 
duced some  years  ago  by  Dr.  Arnott,  of  London.  It 
was  more  particularly  applied  to  the  treatment  of  stric- 
tures, though  reference  is  made  to  its  utility  in  cases 
of  enlarged  prostate. — Treatise  on  Strictures  of  the 
Urethra,  pp.  163  and  178. 

Dr.  Physick  has  lately  adopted  a  similar  practice, 
with  the  most  gratifying  success.  He  was  consulted  in 
the  case  of  an  elderly  gentleman  of  this  city,  who  has 
laboured  for  nine  years  under  a  disease  of  the  prostate, 
and  has  suflfered  severely  from  occasional  attacks  of 
retention  of  urine,  requiring  the  use  of  the  catheter. 
On  a  late  occasion.  Dr.  P.  was  called  to  him,  suffering 
under  an  unusually  severe  attack,  the  continuance  and 
severity  of  which  had  almost  exhausted  him.  He  pre- 
pared a  small  flexible  catheter,  to  the  extremity  of  which 
was  attached  a  ])ortion  of  very  thin  bladder,  firmly  se- 
cured by  silk  thread,  which  was  covered  with  wax.  The 


ENLARGED  PROSTATE.  259 

instrument  tlius  prepared  was  introduced  without  much 
dilhcuhy  into  the  bladder.  Warm  water  was  then  in- 
jected through  the  catheter,and  the  bag  thus  distended. 
An  attempt  was  then  made  to  withdraw  the  instrument. 
As  the  distended  bag  entered  the  passage  through  the 
prostate,  considerable  pain  was  produced;  but  it  was 
allowed  to  remain  for  some  minutes  in  this  situation, 
and  was  finally  brought  through  by  gradual  means. 
Some  blood  flowed  on  withdrawing  the  instrument. 
The  operation  afforded  speedy  relief,  the  health  of  the 
patient  rapidly  improved,  and  he  remained  free  from  a 
return  of  his  symptoms  for  more  than  a  year. 

The  result  of  this  case  is  truly  gratifying;  in  it  we 
perceive  the  skilful  application  of  means  in  the  hands 
of  one,  who  though  advanced  in  life,  is  still  active  in 
his  efforts  to  relieve  afflicted  humanity. 

I  am  now  willing  to  suggest  the  result  of  my  own  re- 
flections on  this  subject,  after  premising  that  they  are 
predicated  on  a  case  related  to  me  by  my  beloved  and 
departed  preceptor.  Dr.  Wistar.  He  tapped  the  dis- 
tended bladder  of  an  elderly  gentleman  above  the  pubis, 
in  consequence  of  his  inability  to  introduce  a  catheter; 
the  difficulty  being  caused  by  an  enlargement  of  the 
prostate  gland.  In  this  instance  the  patient  wore  a  gold 
tube,  in  the  opening  made  by  the  operation,  through 
which  the  urine  was  discharo[ed  without  difficulty. 
From  having  been  the  subject  of  great  sufTering  for 
years,  he  was  by  this  means  enabled  to  enjoy  compa- 
rative comfort;  his  health  improved,  and  was  so  far 
restored  that  he  was  in  the  practice  of  riding  out  to  his 
country  seat,  several  miles  from  the  city,  not  only  in 
his  carriage,  but  sometimes  on  horseback.  Nearly  two 
years  elapsed  under  this  favourable  change.   In  the  in- 


260  TREATMENT  OF 

terim  the  diseased  prostate  had  so  far  recovered,  that 
the  patient  could  pass  water  through  the  urethra  freely 
and  without  pain.  Thinking  that  the  disease  was  cured, 
he  removed  the  tube,  and  relied  entirely  upon  the  natu- 
ral passage.  The  consequence  was,  a  renewal  of  the 
disease  in  the  prostate,  of  which  he  finally  died.  A 
small  fistulous  opening  continued  above  the  pubis,  but 
the  bladder  never  rose  sufficiently  high  to  admit  of  a 
repetition  of  the  tapping,  and  the  tube  could  not  be 
replaced. 

The  striking  relief  experienced  in  this  case,  is  evi- 
dently to  be  referred  to  the  removal  of  the  sources  of 
irritation  to  which  the  diseased  parts  were  subjected. 
If  a  surgeon  is  called  to  a  case  of  inflamed*  knee-joint, 
he  orders  the  patient  to  bed,  and  fixes  the  limb  in  a 
carved  splint,  thereby  suspending  all  motion  in  the  joint. 
He  reasonably  calculates,  that  so  long  as  the  move- 
ments of  the  part  are  permitted,  inflammation  and  its 
consequences  may  be  expected. 

The  situation  of  the  prostate  gland  is  even  worse 
than  that  of  an  inflamed  joint,  because  in  the  latter,  the 
patient  may  recline  on  his  bed,  and  thus  temporarily 
suspend  the  motions  of  the  part.  But  the  silence  of 
midnight  brings  no  settled  repose  to  the  patient  with 
enlarged  prostate;  his  slumbers  are  short,  and  he  is 
frequently  aroused  to  the  renewal  of  painful  efforts, 
which  are  constantly  aggravating  his  disease. 

Now  let  us  apply  the  same  principles  of  treatment  to 
the  enlarged  and  irritable  prostate,  and  if  figurative  lan- 
guage may  be  allowed,  let  it  be  placed  in  a  splint,  or  in 
other  words  let  its  functions  be  suspended.  This  may 
be  accomplished  by  tapping  the  bladder  above  the  pu- 
bis, and  establishing  another  outlet  for  the  urine. 


ENLARGED  PROSTATE.  261 

Possessing  as  I  do,  but  little  confidence  in  the  reme- 
dial agents  employed  for  the  cure  of  enlarged  pros- 
tate, and  viewing  even  palliative  means,  in  some  in- 
stances uncertain,  T  have  arrived  at  the  conclusion, 
that  if,  in  the  dispensations  of  Providence,  I  should 
ever  be  subjected  to  this  malady,  I  would  certainly 
avail  myself  as  a  last  resort,  of  the  operation  of  tap- 
ping the  bladder  above  the  pubis.  It  would  be  far  pre- 
ferable for  a  man  in  advanced  life,  to  be  subjected  to 
the  inconvenience  of  wearing  a  tube,  through  which  his 
urine  could  be  discharged,  than  to  be  afflicted  with  a 
painful  malady,  by  which  he  would  be  led  to  a  slow  and 
painful  death. 


The  following  cases  are  selected  as  illustrating  the 
manner  in  which  the  enlargement  of  the  prostate  gland 
interferes  with  the  discharge  of  urine. 


CASE  XVI. 


NOTE. 


The  subject  of  the  present  note  was  a  respectable 
and  wealthy  merchant  of  Philadelphia,  who,  after  ac- 
quiring a  handsome  estate,  retired  from  business,  to 
spend  the  remainder  of  his  life  surrounded  by  the  com- 
forts of  a  happy  home;  but  he  was  assailed  by  a  pain- 
ful and  protracted  disease,  which,  after  years  of  suffer- 


262  TREATMENT  OF 

ing,  closed  his  life.  My  excellent  and  departed  friend, 
Dr.  Samuel  P.  Griffitts,  was  repeatedly  associated  with 
me  in  consultation  in  the  case. 

I  was  called  to  visit  him  in  the  winter  of  1809.  I 
was  sent  for  in  the  night.  He  was  labourinsf  under  vio- 
lent  pain,  which  was  supposed  to  be  colic,  but  an  exa- 
mination proved  it  to  be  situated  in  the  urinary  organs. 
The  patient  suffered  great  distress,  and  was  unable  to 
pass  his  urine.  The  catheter  was  introduced,  and  I 
was  obliged  to  repeat  it  two  or  three  times  a  day  dur- 
ing the  violence  of  the  symptoms,  and  had  to  resort  to 
the  usual  treatment  by  the  warm  bath,  opiates,  &c., 
with  moderate  depletion.  Under  this  course,  his  more 
urgent  symptoms  abated,  but  the  inability  to  pass  the 
urine  without  the  aid  of  the  catheter  continued,  and  re- 
quired my  attention  for  a  long  time. 

As  the  warm  weather  approached,  he  was  desirous 
of  spending  the  summer  at  his  country  seat,  about  six 
miles  from  the  city.  He  had  a  very  intelligent- coloured 
lad  who  waited  on  him,  and  I  taught  this  lad  the  use 
of  the  catheter,  so  that  he  could  introduce  it  very  well. 

When  the  patient  returned  to  the  city  in  the  autumn, 
my  attendance  on  him  was  resumed.  He  still  required 
the  use  of  the  catheter,  although  his  condition  was 
much  improved,  and  he  enjoyed  considerable  comfort. 
His  disposition  was  naturally  cheerful,  and  his  consti- 
tution had  not  yet  become  very  seriously  injured  by 
the  disease. 

In  the  \Yinter  of  1812 — 13, 1  was  called  one  night 
out  of  bed,  and  found  him  complaining  of  great  pain, 
attended  with  considerable  fever,  and  with  great  ex- 
ertion, he  could  pass  but  a  very  small  quantity  of 
urine.    I  attempted  to  relieve  him  by  the  usual  plan  of 


ENLARGED  PROSTATE.  263 

passing  the  catheter,  but,  for  the  first  time  during  my 
long  attendance,  I  could  not  succeed.  A  very  consider- 
able hemorrhage  from  the  urethra  followed  my  re- 
peated eflbrts  to  introduce  the  instrument.  As  I  used 
the  sum  elastic  catheter,  and  was  confident  that  no 
force  had  been  employed,  sufficient  to  injure  the  ure- 
thra, I  referred  the  hemorrhage  to  a  turgid  and  inflamed 
state  of  the  urethra,  and  was  rather  pleased  with  its 
occurrence,  believing  that  it  would  have  a  salutary 
influence  on  the  local  inflammation.  In  this  I  was  not 
disappointed.  Slight  bleeding  occurred  through  the  fol- 
lowing day;  the  warm  bath  with  venesection  was  em- 
ployed; the  bowels  were  opened;  opiates  were  admi- 
nistered; and,  as  the  inflammation  subsided,  the  urine 
was  discharged,  and  temporary  relief  was  experienced. 

About  this  time  he  was  deprived  of  his  wife,  by  a 
short  and  severe  illness.  This  domestic  affliction  was 
followed  by  an  aggravated  form  of  his  primary  dis- 
ease. The  irritable  state  of  the  urinary  organs  required 
frequent  efforts  to  pass  small  quantities  of  urine,  by 
night  as  well  as  by  day. 

Dr.  Griffitts  and  myself  w^ere  often  earnestly  en- 
treated to  render  him,  if  possible,  some  effectual  relief, 
but  our  united  efforts  proved  vain.  His  general  health 
sunk  under  his  accumulated  sufferings;  from  a  portly 
old  man,  of  a  healthy  and  rather  fforid  countenance,  he 
became  pale  and  emaciated;  hectic  irritation  ensued, 
and  all  that  remained  within  the  power  of  his  medical 
attendants,  was  to  smooth  his  passage  to  the  grave. 

For  a  considerable  time  before  the  death  of  the  pa- 
tient, the  catheter  could  not  be  passed  into  the  bladder; 
but,  after  the  paroxysm  which  followed  the  death  of  his 


264  TREATMENT  OF 

wife,  he  had  no  attack  of  retention  of  urine,  requiring 
immediate  rehef. 

Dissection. 

A  post  mortem  examination  revealed  the  true  state 
of  the  case.  The  prostate  gland  was  greatly  enlarged — 
the  third  lobe  particularly  so, — and  the  muscular  coat 
of  the  bladder  presented  a  fine  specimen  of  those  large 
bands  which  resemble  so  strongly  the  musculi  pectinati 
of  the  heart. 


CASE  XVII. 


NOTE. 


The  subject  of  the  present  note  was  an  old  and  re- 
spectable merchant,  of  a  very  attenuated  appearance? 
remarkably  correct  in  his  habits,  and  precise  in  his 
movements.  He  had  never  entered  the  married  state, 
and  in  the  space  of  seventy  years  had  scarcely  ever 
received  a  visit  from  a  physician. 

I  was  called  to  visit  him  at  Moorestown,  N.  J.  in 
consultation  with  my  departed  friend  Dr.  John  Stokes. 
The  following  was  the  history  of  the  case:  his  disease 
commenced  about  two  years  before  my  visit.  He  had 
a  disposition  to  pass  urine  more  frequently  than  usual; 
it  had  gone  on  increasing  until  it  had  arrived  at  a  point 
of  extreme  distress,  which  confined  him  to  his  cham- 
ber, and  generally  to  his  bed. 

His  inclination  to  void  urine  seemed  constant,  and 
but  a  very  small  quantity  was  passed  at  each  effort.  He 


ENLARGED  PROSTATE.  265 

told  me  that  sometimes  he  was  under  the  necessity  of 
urinating  upwards  of  thirty  times  in  the  course  of  one 
night. 

On  introducing  the  finger  per  anum,  I  found  his 
prostate  gland  very  much  enlarged;  it  was  evidently  of 
a  tuberculous  structure.  I  succeeded  in  passing  a  small 
gum  elastic  catheter  into  the  bladder,  through  which 
upwards  of  a  pint  of  urine  flowed,  to  his  great  relief. 
The  catheter  was  allowed  to  remain  in  the  bladder 
until  my  next  visit,  which  I  paid  in  three  days.  I  found 
the  patient  very  much  relieved  since  the  introduction 
of  the  catheter;  it  was  withdrawn,  and  another  intro- 
duced, with  directions  to  renew  it  frequently.  I  did  not 
visit  him  afterward;  but  understood  from  Dr.  Stokes, 
that  after  the  first  introduction  of  the  catheter,  he  suf- 
fered but  little  pain,  though  his  system  sunk  from  con- 
stitutional irritation,  and  he  died  in  a  few  weeks. 


Passage  of  the  Catheter  m  Enlarged  Prostate. 

In  the  chapter  on  the  catheter  I  shall  endeavour  to 
lay  down  rules  for  the  introduction  of  the  instrument 
in  cases  of  a  common  character.  As  this  operation, 
in  cases  of  enlarged  prostate  gland,  involves  some  im- 
portant views,  it  is  deemed  proper  to  devote  a  little 
space  to  its  special  consideration  in  this  place. 

In  the  preceding  pages,  I  have  endeavoured  to  give 
a  clear  idea  of  the  enlargement  of  the  third  lobe  of  the 
prostate  gland,  and  have  illustrated  it  by  plates.  This 
enlargement  forms  a  triangular  body,  with  a  wide  base. 

34 


266  TREATMENT  OF 

The  general  directions  for  the  use  of  the  catheter  will 
apply  equally  well  to  cases  affected  with  this  disease, 
until  the  instrument  arrives  at  the  extremity  of  the 
prostatic  portion  of  the  urethra.  If  any  difficulty  occurs, 
the  introduction  of  the  finger  into  the  rectum  will  ena- 
ble the  surgeon  to  give  such  a  direction  to  the  point  of 
the  catheter,  (either  by  pushing  it  up  toward  the  sym- 
phisis pubis,  or  toward  either  side  of  the  gland,)  that  it 
will  enter  so  far  within  this  portion  of  the  canal,  as  to 
prevent  the  point  from  being  felt.  He  has  now  arrived 
at  the  most  difficult  part  of  the  operation,  and  the  fin- 
ger in  the  rectum  can  no  longer  aid  him.  The  instru- 
ment may  be  made  to  pass  forward  until  its  further 
progress  is  arrested  by  the  inflamed  and  tense  third 
lobe,  which  acts  like  a  valve  in  closing  the  aperture  of 
the  bladder. 

The  position  of  the  point  of  the  catheter,  though  it 
can  no  longer  be  felt,  is  well  understood  by  the  expe- 
rienced surgeon.  It  is  firmly  pressed  against  the  en- 
larged third  lobe  at  its  base.  If  an  improper  degree  of 
violence  were  used  with  a  silver  catheter,  it  might  pos- 
sibly force  its  way  through  this  part  of  the  gland  into 
the  bladder.  "  Arte  non  vP''  is  here  the  proper  maxim. 

Instead  of  using  force,  the  operator  must  try  to  elude 
the  difficulty  by  referring  to  the  exact  position  of  the 
parts.  By  withdrawing  the  stilet,  he  may  sometimes 
succeed  in  causing  the  point  of  a  flexible  catheter  to 
advance  towards  the  symphisis  pubis,  and  thus  slip 
under  the  third  lobe  into  the  bladder.  Sometimes  the 
silver  catheter  may  be  so  directed  as  to  cause  its  point 
to  take  somewhat  the  same  direction,  by  drawing  it 
gently  but  firmly  up  toward  the  pubis;  while,  at  the 


ENLARGED  PROSTATE.  267 

same  time  the  handle  of  the  instrument  is  depressed  as 
far  as  possible. 

Should  these  methods  fail,  an  attempt  may  be  made 
to  cause  the  catheter  to  ascend  into  the  bladder  by  the 
side  of  the  lobe,  as  there  is  a  cleft  on  each  side,  between 
this  lobe  and  the  two  lateral  lobes.  To  pass  the  instru- 
ment on  either  side,  requires  a  lateral  curvature  of  the 
point  of  the  catheter,  and  in  this  way  it  sometimes  hap- 
pens that  it  enters  the  bladder. 

I  was  once  called  in  consultation  to  the  Pennsylvania 
Hospital,  to  a  case  of  difficulty  in  passing  the  catheter. 
The  instrument  with  the  included  stilet  was  introduced 
as  far  as  it  could  be  advanced,  and  the  urine  flowed  out 
through  the  instrument  by  the  side  of  the  stilet;  but 
on  withdrawing  the  latter,  the  flow  of  urine  immediately 
ceased,  and  on  again  introducing  it,  it  was  resumed.  I 
mentioned  to  my  colleagues,  that  I  believed  the  prostate 
gland  to  be  enlarged,  and  that  the  third  lobe  closed  up 
the  passage  at  the  neck  of  the  bladder,  eflectually  pre- 
venting the  complete  entrance  of  the  instrument.  That 
when  the  stilet  was  in  the  catheter,  it  raised  up  the 
third  lobe,  which  acted  as  a  valve,  and  permitted  the 
discharge  of  urine  by  the  side  of  it;  but  when  it  was 
withdrawn,  the  elastic  catheter  not  being  sufficiently 
firm  to  resist  the  closure  of  the  orifice  by  the  valve-like 
third  lobe,  the  flow  of  urine  ceased.  The  patient  and 
his  friends  being  afraid  of  an  operation,  he  was  taken 
out  of  the  Hospital,  and  soon  after  died  under  the  care 
of  Dr.  Barton. 

On  examination  after  death,  the  case  presented  the 
appearances  which  had  been  supposed  to  exist.  This 
case  led  me  to  the  contrivance  of  the  apparatus  illus- 
trated in  pi.  4.  fig.  1  and  2. 


268  TREATMENT  OF  ENLARGED  PROSTATE. 

This  apparatus  consists  of,  first,  a  flexible  metallic 
canula,  (fig.  1,)  with  a  solid  beak,  but  furnished  with  one 
eyelet  hole,  (a.)  corresponding  in  position  with  the  two 
little  notches  (5.)  on  the  elevated  rim  of  the  instrument. 
The  eyelet  hole  communicates  freely  with  the  cavity  of 
the  barrel  of  the  canula  toward  the  open  extremity  of 
the  latter.  Toward  the  beak,  the  groove  formed  by 
the  continuation  of  the  canal,  terminates  in  an  inclined 
plane  rising  toward  the  inner  end  of  the  eyelet. — 
Second,  a  flexible  elastic  catheter,  which  will  readily 
enter  the  bore  of  the  canula,  and  which,  when  thrust 
forward  as  far  as  the  eyelet,  is  raised  by  the  in- 
clined plane,  and  compelled  to  shoot  out  through  the 
eyelet  hole,  so  as  to  receive  a  rapid  curvature  in  that 
direction,  taking  the  position  represented  in  fig.  2.  The 
point  of  the  flexible  elastic  catheter  being  seen  at  c. 

It  will  be  perceived  that  the  indications  fulfilled  by 
this  apparatus  are  few  and  simple.  The  canula  is  suffi- 
ciently ductile  to  take  and  retain  any  curvature  that 
maybe  required  in  its  introduction,  and  it  is  sufficiently 
firm  to  push  up  and  support  the  third  lobe,  while  the 
flexible  elastic  catheter  seeks  a  passage  through  the 
space  thus  rendered  free.  Before  the  introduction,  the 
eyelet  hole  may  be  made  to  present  forward,  or  to  either 
side,  thus  causing  the  catheter  to  take  a  corresponding 
curvature  in  any  required  direction.  The  notches  on 
the  rim  of  the  canula  indicate  to  the  surgeon,  at  all 
times,  the  actual  position  of  the  eyelet.  This  instru- 
ment is  proposed  for  trial.  Candor  requires  that  I 
should  state,  it  has  not  yet  been  tested  by  experience. 


SECTION  IX. 


RETENTION  OF  URINE  FROM  PRESSURE  ON  THE  SPINAL 

MARROW. 

It  is  a  fact  familiar  to  most  practitioners,  that  pres- 
sure on  the  medulla  spinalis  is  invariably  attended 
with  paraplegia  and  a  retention  of  urine.  This  pressure 
may  be  produced  by  various  causes. 

It  is  witnessed  in  surgical  practice  in  cases  of  severe 
injury  inflicted  on  the  spine,  producing  fracture  or  dis- 
location of  some  of  the  vertebrae.  In  violent  concussions 
of  the  spine,  attended  with  effusion  of  blood  within  the 
theca  vertebralis.  In  scrofulous  affections  of  the  bones 
of  the  vertebrae,  resulting  in  the  formation  of  matter 
within  the  cavity,  &:c.  I  have  also  seen  this  state  of 
things  occurring  in  the  progress  of  diseases,  which  fall 
more  particularly  within  the  province  of  the  physician. 

Rheumatic  or  gouty  affections  may  either  suddenly 
or  gradually  cause  pressure  on  the  spinal  marrow,  and 
produce  paraplegia  and  paralysis  of  the  urinary  blad- 
der. When  it  is  recollected  how  peculiarly  liable  are 
the  joints  to  be  attacked  with  gout  and  rheumatism,  it 
is  rather  surprising  that  the  joints  of  the  vertebrae  are 
so  rarely  affected  in  this  way.  Thus  gouty  concretions 
about  the  fingers  not  unfrequently  produce  great  en- 
largement and  deformity  of  the  parts,  accompanied  with 
anchylosis.  The  same  thing,  I  have  no  doubt,  may  take 
place  in  the  spine;  but,  happily,  its  occurrence  is  very 
rare.  When  it  does  occur,  the  bladder  becomes  involved, 
and  the  catheter  is  required.    The  disease  may  be  mis- 


270  RETENTION  FROM  PRESSURE 

taken  for  an  idiopathic  affection  of  this  organ,  when  in 
reaUty  its  true  seat  is  in  the  medulla  spinalis:  as  in  the 
following  case. 


CASE  XVIII. 

In  the  year  1816,  I  was  requested  to  visit  an  aged 
and  most  respectable  matron,  the  wife  of  a  farmer,  re- 
siding thirty  miles  from  Philadelphia.  Her  medical 
attendant,  a  highly  respectable  physician,  was  treating 
the  case  as  a  primary  affection  of  the  kidneys  or  bladder; 
and  when  I  was  called,  she  was  under  the  use  of  a  de- 
coction of  uva  ursi. 

On  examination,  I  found  that  she  laboured  under  pa- 
raplegia, and  that  the  affection  of  the  bladder  was  sim- 
ply a  consequence  of  serious  and  deep-seated  affection, 
causing  pressure  on  the  spinal  marrow.  She  w^as  afflicted 
with  rheumatism,  and  upon  an  accurate  investigation 
of  the  case,  I  felt  satisfied  that  the  disease  must  have 
arisen  from  the  thickening  of  the  parts  about  the  ver- 
tebrae, gradually  inducing  pressure  on  the  spinal  mar- 
row, which  resulted  in  paraplegia.  This  patient  died; 
but  I  believe  no  post  mortem  examination  was  made. 


I  have  seen  paraplegia  suddenly  induced,  and  depend- 
ing, as  1  have  supposed,  either  upon  severe  inflamma- 
tion terminating  in  effusion  within  the  theca  vertebralis, 
or  upon  the  sudden  cflfusion  of  blood,  as  in  apoplexy. 


ON  THE  SPINAL  MARROW.  271 


CASE  XIX. 

In  the  winter  of  1825—6,  T.  W.,  a  young  man  en- 
dowed with  an  uncommonly  intelhgent  mind,  and  an 
equally  amiable  disposition,  whose  promise  of  talents 
and  usefulness  was  of  no  common  order;  was  attacked 
one  night,  with  most  violent  pain  in  the  lumbar  region. 
He  was  one  of  my  private  pupils,  and  resided  with  his 
father.     His  suftering  was  so  intense,  that  Dr.  Harts- 
home,  who  resided  in  the  immediate  neighbourhood, 
was  called  to  him  in  the  night,  and  prescribed  for  him. 
Soon  after  it  was  discovered  that  he  was  in  a  state  of 
paraplegia.  His  uncle,  the  late  Dr.  S.  P.  Griffitts  and  my- 
self, saw  him,  with  Dr.  Hartshorne,  on  the  following 
morning.  The  paralytic  state  of  his  bladder  required  the 
regular  use  of  the  catheter.  The  patient  gradually  reco- 
vered, so  far  as  to  be  able  to  walk  about,  but  nearly  two 
months  elapsed  before  he  could  leave  his  bed.     There 
was  always  a  perceptible  weakness  in  his  lower  extre- 
mities.    He  graduated  in  the  University  of  Pennsylva- 
nia, and  commenced  practice,  but  in  the  spring  of  1830, 
he  died  of  pulmonary  consumption. 

Paralysis  of  the  bladder  produced  by  pressure  on  the 
spinal  marrow,  may  be  followed  by  ulceration  and  lesion 
of  the  oriran.  The  abstraction  of  nervous  influence 
from  the  bladder,  has  a  tendency  to  weaken  its  vital 
energies.  The  perfect  coaptation,  and  harmonious 
action  of  the  different  parts  of  the  organ  are  interrupted, 
and  irregular  action  ensues.  Inflammation  takes  place, 
but  instead  of  being  phlegmonous  and  restorative,  it  is 


272  RETENTION  FROM  PRESSURE 

erysipelatous  and  destructive.  The  ulcerative  process 
follows  as  a  consequence.  The  bladder  yields  to  a 
solution  of  continuity  in  its  structure,  which  under  a 
combined  and  vigorous  action  of  all  its  constituent 
parts,  would  have  been  successfully  resisted.  I  believe 
this  fact,  and  probably  the  explanation  here  offered  has 
been  published  within  a  few  years  by  an  English  phy- 
sician. I  know  not  where  to  refer,  or  I  would  surely  do 
full  justice  to  the  author. 

A  highly  interesting  case,  illustrating  this  state  of 
things,  occurred  in  my  own  practice. 


CASE  XX. 

Injured  Spine — Inflammation  and  Ulceration  of  the 

Bladder. 

■  In  the  spring  of  1819,  C.  H.  P.,  a  young  man  pos- 
sessing great  muscular  activity,  who  is  reported  to  have 
performed  some  extraordinary  feats  in  running  and 
jumping,  met  with  the  following  accident,  which  caused 
his  death. 

One  night,  on  returning  to  his  lodgings,  he  placed 
his  arm  round  a  tree  before  the  door,  bent  his  body 
backwards,  and  commenced  the  operation  of  whirling 
himself  round  with  great  velocity.  While  thus  engaged, 
he  was  suddenly  seized  with  a  sense  of  heat,  (as  he 
described  it,)  in  his  right  side,  followed  by  excruciat- 
ing pain.  He  walked  into  the  house,  and  the  family 
supposed  he  was  affected  with  colic. 

The  family  physician,  Dr.  Caldwell,  was  called,  and 


ON  THE  SPINAL  MARROW.  273 

some  blood  was  taken  from  his  arm.  About  half  an 
hour  after  the  attack,  he  became  perfectly  easy;  but  by 
this  time,  he  was  in  a  state  of  paraplegia. 

I  was  called  about  forty-eight  hours  after  the  acci- 
dent, for  the  purpose  of  introducing  a  catheter  into  the 
bladder,  which  was  much  distended,  as  he  had  passed 
no  urine.  On  examination,  it  appeared  that  he  had  a 
slight  degree  of  power  over  the  muscles  of  the  left  leg 
and  thigh — ^just  enough  to  enable  him  to  give  very 
slight  motion  to  the  limb. — The  right  leg  and  thigh 
were  perfectly  paralysed.  He  had  no  power  over  the 
bladder.  He  was  sensible  of  a  slight  touch  on  the  para- 
lysed limbs;  but  could  bear  to  be  pinched  without 
pain.  This  insensibility  to  pain  extended  up  the  spine 
nearly  to  the  neck.  The  neck  itself  possessed  natural 
feeling — also  the  arms. 

The  case  obviously  resulted  from  pressure  on  the 
spinal  marrow,  most  probably  arising  from  effusion  of 
blood  within  the  theca  vertebralis.  On  this  point  there 
was  a  perfect  coincidence  of  opinion  in  the  consulta- 
tion. It  was  concluded  to  attempt  relief  by  changing 
the  system  with  mercury,  with  the  hope  of  promoting 
the  absorption  of  the  effused  blood;  and,  if  the  state  of 
the  system  required  it,  to  bleed  the  patient  occasion- 
ally. The  mercurial  treatment  failed  in  producing  ptya- 
lism.  We  now  applied  four  large  caustic  issues  to  the 
spine;  one  on  each  side  of  the  upper  dorsal,  and  one  on 
each  side  of  the  lumbar  vertebrae.  Purges  were  freely 
used,  with  the  hope  of  promoting  absorption.  Dr.  T. 
T.  Hewson  was  joined  with  us  in  consultation,  and  con- 
curred in  the  plan  of  treatment. 

At  one  time  we  were  flattered,  in  consequence  of  his 

being  able  to  move  the  right  great  toe.   Several  weeks 
35 


274  RETENTION  FROM  PRESSURE 

before  his  death,  he  complained  of  considerable  pain  in 
the  right  iliac  region.  It  did  not  appear  to  extend  be- 
yond the  linea  alba.  About  a  week  before  his  death 
this  pain  increased;  his  abdomen  became  tympanitic; 
his  pulse  was  more  frequent;  he  had  frequent  nausea; 
his  countenance  sunk;  and  his  strength  failed. 

From  the  time  of  the  accident  there  was  a  necessity 
for  the  use  of  the  catheter,  and  towards  the  close  of  the 
case,  the  bladder  was  so  loaded  with  thick,  bloody,  and 
offensive  mucus,  that  a  very  large  catheter  was  required 
to  draw  off  the  urine.  It  was  found  necessary  some- 
times, cautiously  to  inject  strained  tepid  water,  which 
aided  in  bringing  away  large  quantities  of  mucus. 

About  forty-eight  hours  before  death,  but  a  small 
quantity  of  urine  could  be  obtained  through  the  cathe- 
ter. On  examining  the  bladder  from  the  rectum,  it 
appeared  enlarged,  and  on  pressing  the  finger  against 
it,  I  received  the  idea  that  it  was  filled  with  mucus. 
Instead  of  being  elastic,  as  when  distended  with  urine, 
it  appeared  to  be  indented  by  the  finger,  as  if  it  were  a 
piece  of  dough.  A  few  hours  before  death,  he  said 
something  had  suddenly  given  way.  He  appeared  to 
be  in  great  distress  for  some  time.  All  pain  finally  left 
him,  and  he  died  remarkably  easy,  after  an  illness  of 
about  five  weeks. 

Dissection. 

On  the  day  following  his  death,  Drs.  Caldwell  and 
Hevvson,  and  myself  met;  also  my  pupils,  with  the  pre- 
sent Dr.  George  M'Clellan,  who  was  a  friend  of  the 
deceased.  At  my  request  he  undertook  the  examina- 
tion. 

Abdomen. — The  intestines  were  found  agglutinated 


ON  THE  SPINAL  MAKROW. 


275 


by  adhesive  inflammation,  and  m'ine  was  discovered  in 
the  cavity. 

The  Bladder  exhibited  evidences  of  great  inflamma- 
tion, which  had  run  on  to  suppuration.  There  were  two 
ulcerated  openings  in  it.  The  largest  of  these  was  on 
the  right  side.  It  admitted  the  finger  very  readily.  The 
inner  surface  of  the  bladder  was  covered  with  mucus, 
and  a  gritty  concretion  was  observable,  principally  to- 
ward the  neck  of  the  bladder.  The  w  hole  viscus  was 
greatly  thickened,  and  adhered  to  the  contiguous  parts. 

The  ulcerated  opening  on  the  right  side  of  the  blad- 
der was  attached  to  a  portion  of  intestine,  in  which  the 
ulcerative  process  appeared  to  have  just  commenced. 

There  was  found  an  effusion  of  blood  between  the 
layers  of  the  peritoneum,  exactly  in  the  part  where  the 
patient  complained  of  the  sudden  sense  of  heat  at  the 
time  of  the  accident. 

Spinal  column. — The  vertebrae  were  sawed  through, 
and  the  spinal  canal  exposed,  without  any  morbid  ap- 
pearances being  presented.  We  were  ready  to  doubt 
whether  any  discovery  could  be  made. 

A  considerable  portion  of  the  spinal  marrow  was  dis- 
sected out,  and  on  making  a  transverse  incision  through 
it,  there  was  a  clear  illustration  of  the  case.  A  portion 
of  blood  had  been  effused  in  the  very  centre  of  the  spinal 
marrow;  it  w^as  about  three  inches  in  extent,  and  was 
found  in  that  portion  of  the  medulla  which  corresponds 
to  the  upper  part  of  the  dorsal,  and  the  lower  part  of 
the  cervical  vertebra. 


CHAPTER  II. 


ON  THE  CATHETER. 


There  are  some  preliminary  matters  connected  with 
the  catheter  which,  though  apparently  of  small  conse- 
quence, will,  in  the  aggregate,  be  found  of  importance 
to  the  young  practitioner. 

Catheters,  as  we  have  them,  may  be  divided  into  three 
classes: — the  silver;  the  flexible  metallic;  and  the  flexible 
gum  catheters.  Every  surgeon  should  be  provided  with 
some  of  each  kind.  I  find  it  most  convenient  to  have 
three  silver  stilets;  from  a  large  to  a  small  size.  The 
silver  is  much  more  ductile  than  iron,  and  can  be  made 
to  receive  any  degree  of  curvature  that  may  be  re- 
quired, with  greater  facility.  If  left  in  a  catheter  when 
the  internal  surface  is  wet,  it  is  not  likely  to  rust  and 
destroy  the  instrument. 

To  illustrate  the  subject,  I  have  been  accustomed  to 
exhibit  to  my  pupils  a  flexible  catheter  w^hich  I  bought 
many  years  ago  for  two  dollars  and  fifty  cents.  Now, 
a  dozen  may  be  procured  for  half  that  sum.  For  a 
young  surgeon  not  very  flush  of  money,  such  an  instru- 
ment was,  at  that  time,  quite  an  acquisition.  It  served  a 
most  excellent  purpose  on  several  important  occasions; 
but  it  was  laid  aside  one  day,  with  the  iron  stilet  within 
it.  Sometime  after  this,  on  attempting  to  put  it  in  requi- 
sition, it  was  found,  that  in  consequence  of  the  oxida- 
tion of  the  iron,  it  was  impracticable  to  withdraw  the 


ON  THE  CATHETER. 


277 


stilct;  which  has  never  been  done,  up  to  the  present 
time.  Thus  my  catheter  was  rendered  useless. 

No  surgeon  should  ever  leave  his  house  without  hav- 
ing catheters  about  him,  especially  if  he  is  to  go  into 
the  country.  It  would  be  easy  to  cite  cases  to  show  the 
importance  of  this  rule,  and  to  show,  also,  the  neglect 
which  at  one  time  pervaded  the  country  practitioners 
on  this  subject.  I  have  long  been  accustomed  to  tell 
my  pupils,  that  although  I  am  a  man  of  peace,  and,  on 
principle  opposed  to  war  in  every  form,  yet  I  aliuays  go 
armed; — not,  however,  with  pistols  or  fire-arms^ — but 
with  catheters,  or  water-arms. 

I  am  accustomed  to  select  flexible  catheters  of  such 
sizes,  that  one  may  be  placed  inside  of  another,  and  in 
this  way  three  may  be  fitted  together.  They  are  car- 
ried in  a  curved  side  pocket  of  sufficient  depth  to  con- 
ceal them.  The  pocket  must  be  covered,  for  some  dis- 
tance up,  with  buckskin,  or  else  the  catheters  will  soon 
work  their  way  through  the  linen,  and  may  be  lost. 
This  I  know  from  experience. 

A  proper  curvature  for  a  silver  catheter  is  a  matter 
of  great  importance.  A  plate  in  Hey's,  and  also  in 
Dorsey's  Surgery  is  very  well  adapted  to  the  purpose. 
I  have  had  for  many  years,  an  excellent  silver  catheter, 
curved  by  Iley's  plate.  A  surgeon  may  be  placed  in  a 
situation  where  he  may  resort  to  a  substitute,  as  pro- 
posed by  the  late  Dr.  Dorsey.  lie  took  the  wire  from 
his  elastic  suspenders,  covered  it  with  waxed  cloth,  and 
succeeded  in  passing  this  instrument  into  the  bladder. 

Directions  for  the  Use  of  the  Catheter, 

The  catheter  should  be  dipped  into  warm  water,  or 
held  before  the  fire  to  raise  the  temperature,  and  it 


278  ON  THE  CATHETER. 

should  then  be  lubricated  with  sweet  oil,  or  some  other 
unctuous  matter.  A  large  catheter,  in  an  unpractised 
hand,  may  be  introduced  more  readily  than  a  small 
one.  This  fact  is  important  to  the  young  practitioner, 
for  he  might  naturally  adopt  an  opposite  conclusion.  A 
small  catheter  may  be  easily  impeded  by  becoming  en- 
tangled in  the  lacunae  of  the  urethra,  which  accident 
sometimes  causes  much  pain;  while  a  large  catheter 
that  fills  up  the  urethra,  cannot  diverge  from  one  side  to 
the  other,  and  distends  the  canal  as  it  advances.  This 
subject  may  be  illustrated  by  the  common  operation  of 
giving  an  enema.  If  this  be  attempted  by  a  bungling 
hand,  the  small  pipe  may  deviate  from  the  centre  of  the 
anus,  and  become  hitched  on  the  side  of  the  sphincter, 
causing  no  little  pain  to  the  patient.  If  the  same  ope- 
rator were  to  attempt  the  introduction  of  the  finger  in 
ano,  after  lubricating  it  with  oil,  he  would  accomplish 
his  purpose  without  difiiculty;  because  the  finger  dilates 
the  parts  as  it  passes  onward. 

In  the  introduction  of  the  catheter  into  the  bladder, 
an  accurate  anatomical  knowledo-e  of  the  relative  situa- 
tion  of  the  contiguous  parts  may  prove  of  essential  ser- 
vice. One  of  the  first  difficulties  is  met  with  in  passing 
the  instrument  under  the  arch  of  the  pubis.  It  is  some- 
times necessary  to  pass  it  downward  as  far  as  it  will 
advance,  with  its  convex  part  toward  the  pubis;  then, 
drawing  the  penis  upon  it,  to  give  it  a  semi-rotatory 
motion,  pushing  it  gently  forward  at  the  same  time, 
until  its  concave  surface  is  presented  toward  the  pubis 
in  a  line  with  the  linea  alba. 

After  the  catheter  has  passed  under  the  pubic  arch, 
it  will  soon  enter  the  membranous  portion  of  the  ure- 
thra.   If  any  difficulty  arises  at  this  point,  two  modes 


ON  THE  CATHETER.  279 

may  be  adopted  to  relieve  it.  The  index  finger  should 
be  introduced  into  the  rectum,  and  tlic  point  of  the  in- 
strument may  be  felt  through  the  bowel  in  the  mem- 
branous portion.  While  the  operator  holds  the  instru- 
ment with  one '  hand  ready  to  push  it  forward,  he  can, 
with  the  finger  of  the  other  hand,  elevate  the  point  di- 
rectly in  front  of  the  opening  in  the  prostate  gland. 
This  will  generally  prove  successful,  and  the  catheter 
w^ll  then  enter  the  bladder.  The  surgeon  may  also  give 
a  lateral  direction  to  the  point  of  the  instrument,  if 
required;  and  this  is  sometimes  of  the  utmost  conse- 
quence in  a  diseased  state  of  the  prostate  gland. 

If  a  flexible  gum  catheter  with  a  stilet  be  used,  the 
curvature  of  the  instrument  may  be  varied,  and  its 
point  turned  to  the  upper  side  of  the  urethra  by  gently 
withdrawing  the  stilet  a  little  distance.  This  may  be 
made  clearly  to  appear,  by  drawing  a  stilet  from  a  ca- 
theter before  its  introduction. 

Some  of  the  flexible  metallic  catheters  have  a  small 
probe-pointed  projection  beyond  the  common  round 
termination,  so  as  to  enter  a  contracted  or  strictured 
part,  and  lead  the  way  before  the  instrument.  Some 
catheters  are  formed  small  at  the  point,  and  very  gra- 
dually increasing  in  size  toward  the  other  end.  The 
practice,  introduced  by  my  friend  Dr.  Physick,  of  ap- 
pending a  portion  of  waxed  bougie  as  a  point  for  the 
catheter,  (as  directed  in  Dorsey's  Surgery,)  and  allow- 
ing it  to  adapt  itself,  and  become  gently  insinuated  into 
the  part  where  the  obstruction  exists,  is  one  entitled  to 
the  greatest  attention,  and  is  admirably  adapted  to 
elude  some  of  the  most  serious  difficulties  and  dangers 
connected  with  retention  of  urine.  The  distension  of  the 
urethra  by  the  injection  of  warm  olive  oil,  has  been 


^80  ON  THE  CATHETER. 

tried  by  my  friend  Dr.  Thomas  T.  Hewson  with  suc- 
cess. 

In  all  operations  with  the  catheter,  the  greatest 
care  must  be  observed  to  avoid  improper  force.  The 
maxim  '•^  arte  non  vP  is  here  particularly  applicable. 
For  want  of  attention  to  this  rule  the  urethra  may  be 
lacerated  by  unskilful  hands,  to  the  no  small  pain  and 
danger  of  the  patient.  The  variation  of  curvature,  by 
using  a  variety  of  silver  stilets,  some  of  them  with  a 
lateral  bend,  as  recommended  by  Dr.  Dorsey,  I  consider 
very  important.  I  have  also,  upon  the  recommenda- 
tion of  Home,  attempted  to  give  a  permanent  lateral 
curvature  to  catheters,  by  keeping  them  for  a  long  time 
on  stilets  variously  modified.  Sometimes  the  curvature 
required  is  very  great.  I  once  saw  Dr.  Physick  intro- 
duce a  catheter  in  a  case  of  great  difficulty,  in  which 
he  bent  the  instrument  nearly  double.  Sometimes  ca- 
theters may  be  made  to  pass  easily  into  the  bladder 
without  any  stilet. 

I  consider,  as  a  general  rule,  the  recumbent  posture 
greatly  preferable  to  the  erect  position  in  the  passage 
of  the  catheter.  The  straight  catheter,  as  recommended 
particularly  by  the  French  surgeons,  I  have  no  doubt 
is  well  adapted  to  certain  cases,  when  it  is  employed 
by  a  surgeon  familiar  with  its  use. 

When  1  have  met  with  great  difficulty  in  passing  the 
catheter  into  the  bladder,  and  have  finally  succeeded,  I 
have  generally  permitted  it  to  remain  for  a  few  days, 
secured  by  a  tape  passed  round  the  penis,  and  closed 
by  a  cedar  plug,  which  enables  the  patient  to  draw  off 
his  urine  at-  pleasure.  In  the  early  part  of  the  treat- 
ment, if  the  instrument  causes  no  unusual  pain,  I  have 
a  preference  in  permitting  it  to  rest  in  the  canal  for 


ON  THE  CATHETER.  ii81 

several  days.  It  appears  to  -nie  that  the  urethra  be- 
comes inured,  in  this  way,  to  the  presence  of  the  instru- 
ment, and  is  moulded  in  such  a  manner  that  less  sub- 
sequent difficuky  is  experienced  in  its  introduction. 
But  after  the  first  effects  of  retention  have  passed  over, 
I  prefer  the  removal  of  the  catheter  directly  after  draw- 
ing off  the  urine;  repeating  the  introduction  every 
morning  and  evening,  or  oftener  if  required.  Advantage 
may  now  be  derived  from  encouraging  the  patient  to 
make  moderate  efforts  to  relieve  himself  in  the  natural 
way.  In  some  instances,  weeks,  or  even  months  may 
elapse  before  the  use  of  the  catheter  can  be  dispensed 
with. 

The  slowness  of  return  to  a  healthy  condition,  in 
many  cases  of  retention,  cannot,  in  my  opinion,  be  re- 
ferred to  a  paralytic  condition  of  the  urinary  organs. 
If  this  condition  were  present,  incontinence  of  urine 
would  be  the  result;  but  this  is  not  the  case.  I  have  fre- 
quently requested  my  patients,  while  the  catheter  was 
in  the  bladder,  to  make  efforts  to  expel  the  urine.  The 
force  with  which  it  is  propelled  through  the  instrument 
on  such  occasions,  gives  decisive  evidence  of  muscular 
power  in  the  bladder.  The  perfect  freedom  with  which 
a  "large  catheter  may  be  passed,  shows  clearly  that  no 
stricture  or  mechanical  impediment  is  in  the  way.  What 
then  is  the  cause  of  the  difficulty?  I  am  inclined  to  at- 
tribute it  to  the  loss  of  those  sympathetic  and  harmo- 
nious actions  between  contiguous  parts,  which,  in  a 
healthy  condition,  are  so  nicely  adjusted,  and  so  accu- 
rately maintained.  I  have  either  read  or  heard  a  simile 
which  places  the  subject  in  a  clear  light;  whence  it  is 
derived  I  am  now  unable  to  state.  The  bladder  and 
urethra  are  compared  to  two  horses  in  a  wagon  who 

36 


282  DIFFICULTY  OF  PASSING  THE  CATHETER 

are  false  to  the  draft;  when  one  pushes  forward,  the 
other  pulls  back,  and  when  the  latter  advances,  the  for- 
mer pays  him  in  his  own  coin,  and  refuses  to  move; 
hence  it  requires  no  little  skill  and  patience  in  the 
driver  to  adjust  the  difficulty.  It  is,  I  presume,  on  the 
principle  of  restoring  the  harmonious  action  of  conti- 
guous parts,  that  Dr.  Gibson  has  suggested,  in  cases  of 
retention,  the  practice  of  pouring  water  from  a  consi- 
derable height  into  a  vessel  beneath,  in  the  presence  of 
the  patient,  a  practice  which  he  has  tried  with  benefit, 
especially  in  infants.  He  was  led  to  adopt  this  course 
from  the  custom  of  experienced  ostlers,  who  place  fresh 
straw  under  a  horse,  and  cause  a  rustling  noise,  which, 
it  is  well  understood,  invites  the  animal  to  a  discharge 
of  urine. 


SECTION  I. 


DIFFIOULTY  IN  THE  PASSAGE  OP  THE  CATHETER  PROM  AN 
EFFUSION  OP  BLOOD. 

Difficulties  are  sometimes  experienced  in  passing  the 
catheter,  from  unsuspected  causes.  It  is  very  important 
for  the  surgeon  to  be  aware  of  these,  and  of  the  means 
of  overcoming  them. 

I  shall  first  notice  the  eflfusion  of  blood  into  the  ure- 
thra. In  the  course  of  my  practice,  I  have  sometimes 
met  with  an  impediment  in  the  passage  of  the  catheter, 
which  I  was  at  one  time  unable  to  explain. 

When  the  instrument  has  been  passed  as  far  down 
as  the  arch  of  the  pubis,  instead  of  keeping  its  usual 


FROM  AN  EFFUSION  OP  BLOOD.  283 

course,  I  have  been  sensible  that  the  point  took  a  late- 
ral direction,  and  have  been  impressed  with  a  fear,  that 
if  I  were  to  continue  to  push  it  forward,  the  uretha 
might  be  pierced  on  its  side.  A  case  occurred  to  me 
some  years  ago,  which  enabled  me  to  ascertain  the 
cause  of  this  difficulty. 


CASE  XXI. 

3d  mo.  21st,  1819.  I  was  attempting  to  pass  the  ca- 
ther,  in  the  case  of  R.  D.,  an  old  and  respectable  citi- 
zen, who  had  been  for  a  long  time  afflicted  with  calculi 
in  the  bladder,  and  for  whom  I  had  frequently  passed 
the  instrument  without  difficulty. 

In  this  instance  I  was  unexpectedly  foiled  in  my 
first  attempts.  I  perceived  some  blood  at  the  ori- 
fice of  the  urethra;  this  I  considered  of  no  import- 
ance, and  pushed  in  the  instrument  as  usual.  The 
catheter  carried  something  before  it,  as  it  passed 
down  the  canal,  and  after  entering  for  a  short  dis- 
tance, it  w^as  evident  that  the  urethra  was  completely 
obstructed.  On  withdrawing  the  instrument,  blood 
again  rose  to  the  orifice;  it  was  dark  and  firm,  and 
in  a  coagulated  state.  On  taking  hold  of  the  project- 
ing portion  with  my  finger,  I  drew  out  a  mass  of 
coagulated  blood,  several  inches  in  length,  which 
must  have  nearly  filled  up  the  urethra.  The  catheter 
was  again  introduced.  It  entered  without  difficulty, 
and  passed  along  under  the  arch  of  the  pubis;  here 
it  was  again  resisted,  (so  far  as  I  could  judge  by 
the  sense  of  touch,)  by  the  same  kind  of  mass.     On 


284  DIFFICULTY  OF  PASSING  THE  CATHETER 

firmly,  yet  carefully  pushing  the  instrument  forward,  it 
took  the  lateral  direction,  which  I  had  often  before 
noticed,  but  never  so  fully  understood. 

I  now  believed  that  the  urethra  was  distended  at  this 
part  with  coagulated  blood;  the  catheter  could  not  pass 
through  its  centre,  but  took  a  course  between  the 
coagulum  and  the  side  of  the  urethra,  thus  preventing 
the  entrance  of  the  instrument  into  the  bladder.  I  suc- 
ceeded in  introducino;  it  a  few  hours  afterwards. 

A  short  time  after  this,  the  old  man  died,  after  hav- 
ing suffered  most  severely  from  his  disease.  I  examined 
the  body  after  death,  in  the  presence  of  Dr.  Hartshorne. 
The  prostate  gland  was  very  much  enlarged;  and  I 
took  eight  calculi  from  his  bladder.  Their  average  size 
was  that  of  a  hickory  nut:  they  were  rough  on  the  sur- 
face. 

Remark, 

Reflecting  on  this  case,  I  came  to  the  conclusion, 
that  in  a  similar  instance,  I  would  attempt  to  wash 
out  the  blood  from  the  urethra,  by  the  injection  of 
tepid  water  through  a  small  syringe. 

A  portion  of  water  should  be  injected,  and  retained 
in  the  urethra  by  closing  the  orifice.  By  this  method 
the  water  is  brought  in  contact  with  the  coagulum,  a 
portion  of  which  will  be  dissolved;  this  is  evacuated, 
and  the  operation  repeated,  until  the  whole  mass  is 
removed. 


Another  source  of  embarrassment  connected  with 
efiiision  of  blood,  has  fallen  under  my  notice.  In  this 
instance  the  catheter  is  not  obstructed  in  its  passage  to 
the  bladder, but  the  difficulty  is  to  be  found  in  the  bladder 


FROM  AN  EFFUSION  OF  BLOOD.  285 

itself,  and,  until  the  true  character  of  the  case  is  ascer- 
tained, the  patient  is  involved  in  suffering  and  danger, 
and  his  medical  attendants  in  doubt.  The  following  case 
will  illustrate  my  meaning. 


CASE  XXII. 

In  the  summer  of  1814,  I  was  requested  to  visit  a 
respectable  old  farmer  residing  near  Bustleton,  who 
was  labourincr  under  retention  of  urine.  His  bladder  was 
distended,  and  numerous  efforts  to  introduce  the  cathe- 
ter had  failed.  It  so  happened  that  I  was  instrumen- 
tal in  procuring  relief  for  the  patient.  I  passed  the 
catheter  into  the  bladder,  drew  off  the  urine,  and  re- 
turned to  the  city,  leaving  him  under  the  care  of  his 
physicians,  Drs.  Worthington  and  Smith. 

Nearly  two  weeks  after  this  my  attendance  was 
again  requested,  in  consequence  of  the  occurrence  of 
certain  symptoms  which  it  was  difficult  to  explain.  His 
medical  attendants  found  no  difficulty  in  introducing  the 
catheter,  and  some  bloody  urine  would  occasionally  be 
discharged  through  it.  Still  the  patient  was  not  relieved, 
as  he  had  generally  been,  and  the  bladder  appeared  to 
be  still  distended.  On  examination  I  found  considerable 
fulness  above  the  pubis.  The  symptoms  of  retention 
were  not  so  violent,  as  in  the  first  instance,  but  there 
was  evidently  some  obscure  mischief. 

My  first  object  was  to  ascertain  whether  the  catheter 
actually  entered  the  bladder.  I  introduced  it  with  the 
greatest  ease,  but  no  urine  followed.  On  withdrawing 
the  instrument  and  examining  its  eye,  I  found  it  con 


286  DIFFICULTY  OF  PASSING  THE  CATHETER 

tained  a  portion  of  coagulated  blood.  This  immediately 
led  to  the  suspicion  that  the  bladder  was  filled  with 
blood.  To  test  the  correctness  of  this  conjecture,  I 
returned  the  catheter  into  the  bladder,  and  then  bv 
means  of  a  syringe,  injected  very  cautiously  a  portion 
of  warm  water.  The  finger  was  then  applied  to  the  end 
of  the  catheter  in  order  to  prevent  a  return  of  the  wa- 
ter, supposing  that  if  blood  were  the  cause,  a  por- 
tion of  it  would  be  dissolved.  On  removing  the  finger 
in  a  few  minutes,  bloody  water  escaped  through  the  in- 
strument, and  my  suspicions  were  realized. 

The  whole  case  was  now  perfectly  clear.  I  repeatedly 
injected  warm  water,  retaining  it  as  before,  and  then 
permitting  it  to  escape;  after  every  discharge  the  quan- 
tity of  warm  water  could  be  increased.  In  this  manner 
the  blood  was  gradually  washed  out  of  the  bladder,  to 
the  great  relief  of  the  patient,  and  very  serious  conse- 
quences were  averted. 


It  sometimes  happens,  that  the  surgeon  is  called  upon 
to  pass  the  catheter,  in  cases  complicated  with  inflam- 
mation of  the  urethra,  or  of  the  neck  of  the  bladder. 
This  condition  may  either  be  the  original  cause  of  the 
retention,  or  the  result  of  long-continued  and  injudicious 
efforts  to  introduce  the  catheter  in  unskilful  hands.  In 
these  cases  the  system  is  generally  considerably  excited, 
the  pulse  is  active  and  febrile,  the  skin  is  hot,  and  the 
patient  very  restless.  Under  these  circumstances,  I 
have  generally  made  slight  attempts  to  introduce  the 
catheter;  but  if  it  did  not  pass  easily,  I  have  desisted 
and  advised  the  reduction  of  the  inflammation  by  ve- 
nesection, leeches  to  the  perineum,  &c.  The  warm  bath 


FROM  AN  EFFUSION  OF  BLOOD.  287 

and  opiates,  and  particularly  a  combination  of  calomel 
and  opium,  in  the  proportion  of  eight  or  ten  grains  of 
the  former  to  two  or  three  of  the  latter,  have  had,  on 
some  occasions,  a  very  happy  effect.  After  pursuing 
this  course  for  a  few  hours,  the  threatening  symptoms 
will  generally  yield.  When  the  inflammation  and  con- 
striction of  the  urethra  are  removed,  the  instrument 
may  be  passed  without  difficulty. 


CHAPTER  III. 


STRICTURE  OF  THE  URETHRA. 

It  is  not  my  intention  to  offer  a  systematic  history 
of  this  disease  in  its  multiphed  forms;  but  to  confine 
my  observations  within  defined  Hmits,  referring  to  sys- 
tematic writers  for  such  parts  of  the  subject  as  may  be 
left  untouched. 

A  stricture  consists  in  a  diminution  of  some  part  of 
the  canal  through  which  the  urine  passes  from  the 
bladder.  The  disease  is  often  first  observed  by  a  tem- 
porary difficulty  in  voiding  urine,  which  subsides,  and 
leaves  the  part  in  a  natural  state.  The  urethra,  in  this 
form  of  the  disease,  may  take  on  a  sudden  spasmodic 
action,  whereby  the  size  of  the  canal  is  diminished,  caus- 
ing retention  of  urine,  and  a  difficulty  in  the  introduc- 
tion of  the  catheter  or  bougie. 

A  difference  of  opinion  exists  among  writers,  upon 
the  nature  of  this  spasmodic  contraction  of  the  urethra. 
Some  attribute  it  simply  to  elasticity  in  the  structure  of 
this  part;  while  others  consider  it  as  the  result  of  mus- 
cular contraction.  Although  distinct  muscular  fibres 
may  not  be  demonstrated  in  the  human  urethra,  yet 
they  may  be  traced  in  larger  animals,  and  we  are  thus 
led  to  infer  their  existence.  The  effects  of  muscular 
contraction  are  so  clearly  manifested  in  the  urethra  in 
various  ways,  that  my  own  mind  is  satisfied  on  this 


STRICTURE  OP  THE  URETHRA.  289 

point.     The  existence  of  the  thread-like  stricture  ap- 
pears alone  sufficient  to  establish  the  fact. 

We  see  this  principle  more  obviously  exemplified  in 
the  intestinal  canal.  In  cases  where  death  has  resulted 
from  long-continued  and  violent  spasm  in  this  part,  a 
post  mortem  examination  exhibits  parts  of  the  intes- 
tinal tube,  in  which  a  diminution  of  cahbre  has  oc- 
curred, presenting  an  appearance  very  similar  to  the 
effect  of  a  tape  drawn  around  the  bowel,  so  as  nearly 
to  obliterate  the  passage.  The  same  appearance  is  ob- 
served in  stricture  of  the  urethra. 

The  frequent  repetition  of  spasmodic  action  in  the 
urethra  is  often  followed  by  inflammation  and  thicken- 
ing of  the  affected  part,  and  may  finally  result  in  a  per- 
manent stricture. 

This  more  durable  form  occurs  also  in  the  intestinal 
tube,  under  like  circumstances.  I  was  in  the  practice  of 
attending  an  intimate  friend,  of  this  city,  who  was  a 
plumber  by  trade,  and  was  subject  for  many  years  to 
frequent  attacks  of  colica  pictonum,  and  gout,  of  which 
he  finally  died.  A  post  mortem  examination  exhibited  a 
firm  and  permanent  stricture  of  the  colon. 

The  same  condition  occurs  in  the  oesophagus.  I  well 
recollect,  while  I  was  a  pupil,  the  case  of  a  lady  who 
had  been  for  a  long  time  affected  with  stricture  of  the 
oesophagus,  and  who  died  from  inanition  under  the  care 
of  Dr.  Wistar.  On  examination  after  death,  a  portion 
of  the  tube  was  so  much  thickened,  that  it  would 
scarcely  admit  a  probe. 

Strictures  of  the  urethra  are  accompanied  with  a 

corresponding  diminution  in  the  stream  of  urine.     In 

the  first  stage  of  the  disease  this  symptom  may  scarcely 

be  noticed;  but  as  the  size  of  the  canal  diminishes,  the 

37 


290  STRICTURE  OF  THE  URETHRA. 

Stream  becomes  forked  or  spiral,  like  a  corkscrew;  a 
considerable  time  is  required  to  discharge  the  urine; 
and  finally  it  dribbles  away  in  drops. 

The  patient  generally  experiences  more  or  less  pain 
at  the  stricture,  and  pain  is  sometimes  complained  of 
near  the  extremity  of  the  penis.  A  gleety  discharge  is 
also  a  common  attendant  on  the  disease. 

When  a  stricture  is  so  tight  as  nearly  to  close  the 
canal,  exposure  to  cold,  irregularities  from  intemperate 
drinking,  with  other  causes  of  an  irritating  character, 
may  produce  a  complete  obstruction  and  retention  of 
urine. 

In  some  irritable  individuals,  a  train  of  alarming 
symptoms  may  be  induced  by  the  introduction  of  the 
bougie.  I  once  attended  a  nervous  old  bachelor  with 
stricture.  In  attempting  to  pass  a  bougie  he  was  sud- 
denly attacked  with  a  chill,  and  his  symptoms  were  so 
extremely  violent,  that  I  felt  seriously  uneasy  for  the 
result.  It  resembled  very  much  the  chill  of  a  malignant 
intermittent,  which  sometimes  prostrates  the  patient 
below  the  point  of  reaction,  and  speedily  terminates  in 
death.  Under  prompt  tranquillizing  and  restorative 
treatment  he  recovered. 

The  constant  irritation  to  w^hich  the  urethra  is  sub- 
jected in  cases  of  stricture,  may  be  readily  propagated 
to  the  bladder,  producing  such  frequent  calls  to  urinate 
that  the  real  character  of  the  disease  may  be  over- 
looked. The  kidneys  or  bladder  may  be  suspected  as 
the  primary  seat  of  a  complaint,  which  is  in  reality 
located  in  the  urethra. 

Dr.  Wistar  was  accustomed  to  relate  to  his  pupils 
the  case  of  an  old  and  most  respectable  citizen,  who  was 
under  his  care  with  stricture  of  the  urethra.  He  advised 


STRICTURE  OF  THE  URETHRA.  1291 

the  use  of  bougies,  &c.  To  this  practice  the  patient 
was  extremely  averse,  neither  could  he  comprehend  its 
necessity,  inasmuch  as  he  believed  his  disease  was 
"^raye/."  Under  this  impression  he  travelled  about, 
visiting  a  number  of  mineral  springs,  whose  waters  are 
famed  for  the  cure  of  various  complaints.  He  returned 
home  disappointed,  and  not  improved.  He  now  took 
Dr.  Wistar's  advice;  the  bougie  was  employed,  and  the 
patient  was  restored  to  health. 

Instances  of  this  kind  have  occasionally  fallen  under 
my  own  observation.  I  well  recollect  a  patient  whom 
I  attended  with  stricture,  whose  bladder  was  so  irritable 
that  he  was  subjected  to  great  inconvenience  from  fre- 
quent calls  to  urinate.  The  use  of  the  bougie  soon 
overcame  the  stricture,  and  afforded  him  relief  from 
those  symptoms. 

The  testes  may  also  be  involved  in  serious  disease 
from  a  stricture  in  the  urethra.  This  I  have  repeatedly 
witnessed  in  hospital  practice.  There  is  reason  to  fear 
that  some  patients  have  been  subjected  to  pain  and  mu- 
tilation, who  might  have  been  saved  from  both,  had  the 
practitioner  been  fully  acquainted  with  the  primary  seat 
of  the  mischief. 

I  have  received  much  valuable  information  on  this 
subject  from  the  work  of  "  Ramsden  on  the  Testicles," 
an  author  who  has  devoted  much  time  to  its  investiga- 
tion. 

As  a  general  rule,  strictures  exist  about  the  bulb  of 
the  urethra,  yet  they  sometimes  form  in  other  parts  of 
the  canal.  I  have  seen  two  cases  within  a  very  short 
distance  of  the  point  of  the  urethra. 


SECTION  I. 


TREATMENT  OF  STRICTURE. 


The  more  simple  and  manageable  form  of  stricture, 
lies  within  the  reach  of  mechanical  dilatation  by  the 
bougie.  I  shall  say  but  little  on  these  cases,  referring 
the  reader  to  the  numerous  works  which  treat  at  large 
upon  this  subject.  It  may  be  remarked,  that  even  in 
some  very  discouraging  cases  the  use  of  the  bougie  will 
generally  succeed,  at  least  in  relieving  the  patient,  if 
it  will  not  produce  a  radical  cure.  Even  though  the 
surgeon  is  obliged  to  use  a  very  small  bougie  in  the 
commencement  of  the  treatment,  yet  by  perseverance 
and  gentleness  the  obstruction  gradually  yields. 

At  the  first  introduction,  the  instrument  should  be 
allowed  to  remain  but  a  few  minutes,  as  the  patient 
generally  suffers  severe  pain.  As  the  sensibility  of  the 
part  diminishes,  the  bougie  may  be  longer  retained, 
until  at  last  an  hour  may  elapse,  without  the  patient 
appearing  to  suffer  pain  or  inconvenience.  It  is  gene- 
rally necessary  to  begin  the  process  of  dilatation  with 
a  very  small  bougie,  gradually  increasing  the  size  until 
an  instrument  of  maximum  size  can  be  introduced.  The 
operation  should  be  repeated  daily.  After  the  removal 
of  the  stricture,  a  large  sized  catheter  or  bougie  should 
be  occasionally  introduced,  with  a  view  of  preventing 
a  return. 

It  has  been  previously  stated,  that  patients  with  stric- 
ture are  very  liable  to  an  aggravation  of  the  disease 
from  exposure  to  cold  and  other  causes,  and  that  a 


TREATMENT  OF  STRICTURE.  293 

complete  retention  is  sometimes  the  consequence.  I 
have  occasionally  seen  patients  in  a  very  critical  situa- 
tion from  such  an  occurrence.  The  bladder  has  been 
very  much  distended,  forming  a  tumour  above  the  pubis, 
attended  with  pain,  inflammation,  and  fever.  In  these 
cases  the  indications  consist  of  such  measures  as  are 
calculated  to  reduce  fever  and  inflammation,  allay  pain, 
and  procure  relaxation.  Hence  general  bleeding,  with 
the  application  of  leeches  to  the  perineum,  the  warm 
bath,  either  generally  or  locally  to  the  affected  part, 
with  the  exhibition  of  calomel  and  opium,  will  constitute 
the  general  means  of  relief.  Added  to  these,  the  use  of 
bougies  and  catheters,  of  diflferent  dimensions,  should 
be  tried. 

In  some  of  these  cases,  where  I  felt  greatly  dis- 
couraged, I  have  witnessed  an  unexpected  and  gradual 
abatement  of  the  symptoms,  the  stricture  has  yielded 
to  the  remedies,  and  the  patient  become  able  to  dis- 
charge his  urine.  Although  the  pain  experienced  in  this 
form  of  the  disease  is  considerable,  yet  it  is  not  gene- 
rally so  intense  as  that  felt  by  patients  with  distended 
bladder  suddenly  induced  for  the  first  time.  Perhaps 
this  circumstance  may  be  referred  to  the  fact,  that 
some  patients  with  stricture  of  long  standing,  habitually 
retain  a  portion  of  urine  and  thus  the  bladder  becomes 
so  accustomed  to  the  presence  of  an  unnatural  quan- 
tity of  the  fluid,  that  its  irritating  effects  are  in  some 
degree  diminished. 


The  following  case,  which  fell  under  my  observation 
during  last  w  inter,  presents  an  example  of  the  condi- 
tion noticed  above. 


294  TREATMENT  OF  STRICTURE. 


CASE  XXIII. 

1st  mo.  26th,  1834.  .1.  S.,  a  stout  muscular  man,  who 
had  been  the  captain  of  a  vessel  for  many  years,  had 
been  the  subject  of  permanent  stricture  for  the  last  six 
years;  for  which  he  has  occasionally  used  a  bougie.  I 
was  called  to  see  him  at  one  of  the  hotels,  on  the  even- 
ing of  his  arrival  from  a  journey,  in  which  he  had  been 
exposed  in  a  stage-coach  to  unusually  cold  and  incle- 
ment weather. 

He  had  been  suffering  during  the  day,  from  retention 
of  urine,  being  unable  to  pass  his  water,  except  by  drops. 
The  bladder  was  evidently  considerably  distended.  His 
pulse  was  active  and  febrile,  skin  hot,  and  he  was  suf- 
fering great  uneasiness.  In  addition  to  the  stricture, 
the  patient  was  affected  with  a  severe  catarrh. 

I  attempted  the  introduction  of  the  catheter,  but 
finding  the  stricture  very  firm,  I  desisted  after  slight 
efforts.  He  was  directed  to  be  freely  bled  from  the  arm, 
to  have  a  warm  bath,  and  to  take  pills  of  calomel  and 
opium. 

27th.  The  patient  has  passed  a  restless  night;  blad- 
der considerably  distended.  Has  not  discharged  urine, 
except  a  little  by  drops.  The  introduction  of  the  ca- 
theter was  again  attempted  without  success.  I  directed 
free  leeching  to  the  perineum,  and  castor  oil  to  open 
the  bowels,  diluent  drinks,  warm  bath,  &c.  Frequent 
attempts  were  made  in  the  course  of  the  day  to  intro- 
duce the  catheter,  both  by  myself  and  son,  but  without 
success.  Instruments  of  various  sizes  were  tried,  and 
a  bougie  was  passed  down  to  the  stricture,  and  retained 


TREATMENT  OF  STRICTURE.  295 

there  by  the  patient  for  a  considerable  time.  The 
bowels  were  freely  opened  by  the  medicine;  but  still 
we  were  obliged  to  consign  the  patient  to  another  night 
of  suffering. 

28th. No  improvement;  has  passed  a  distressing  night. 
He  was  again  bled  from  the  arm,  and  the  introduction 
of  the  catheter  faithfully  tried  without  success.  We 
feared  that  it  would  be  necessary  to  resort  to  the 
operation  of  tapping  the  bladder  above  the  pubis.  My 
friend  and  former  pupil,  Dr.  Ashmead,  now  saw  him  at 
my  request.  He  had  lately  returned  from  Paris,  and 
had  with  him  a  great  variety  of  instruments  adapted 
for  cases  of  this  description.  After  trying  a  variety  of 
catheters  without  success,  he  finally  succeeded  in  pass- 
ing the  stricture  with  a  silver  catheter,  having  a  taper- 
ing extremity.  The  end  of  the  instrument  was  firm 
and  pointed,  and  well  calculated  to  enter  a  very  small 
stricture.  This  form  of  catheter  is  recommended  by 
Dupuytren,  and  has  been  frequently  successful  in  his 
hands  in  very  difficult  cases.  In  skilful  hands  it  is  cer- 
tainly an  excellent  instrument;  but  when  used  by  bun- 
gling operators,  its  pointed  extremity  would  be  dan- 
gerous. It  is  scarcely  necessary  to  add,  that  this  pa- 
tient was  relieved  by  the  operation,  and  recovered  his 
usual  health  in  a  few  days. 


On  the  Use  of  Caustic  in  Strictures. 

Some  cases  of  stricture  will  not  yield  to  mechanical 
dilatation,  and  require  to  be  subjected  to  the  operation 


296  TREATMENT  OF  STRICTURE. 

of  the  knife  or  the  caustic.  The  latter  plan  was  re- 
commended and  practised  by  John  Hunter,  and  after- 
ward claimed  the  especial  attention  of  Everard  Home, 
who  has  written  a  voluminous  work  with  a  view  of 
elucidating  its  beneficial  effects. 

The  method  of  applying  caustic  is  a  matter  of  nicety 
and  importance.  Home  recommended  the  plan  of  fixing 
to  the  point  of  the  wax  bougie,  a  piece  of  lunar  caus- 
tic, about  half  an  inch  in  length,  and  about  one-third 
of  the  thickness  of  the  usual  rolls  of  caustic.  The  sides 
of  the  caustic  are  to  be  covered  by  the  bougie  plaster, 
and  the  extremity  only  exposed.  Having  previously 
ascertained  the  depth  of  the  stricture,  the  surgeon 
dips  the  bougie  in  oil  and  passes  it  down  to  the  stric- 
tured  part.  It  is  suffered  to  remain  on  the  stricture  for 
about  a  minute,  and  then  removed.  After  the  removal, 
the  patient  is  desired  to  make  water.  This  operation  is 
repeated  every  two  or  three  days,  until  the  surgeon  has 
evidence  that  the  stricture  is  destroyed. 

This  plan  of  applying  the  caustic  is  attended  with  no 
inconsiderable  trouble,  in  adapting  the  caustic  to  the 
bougie,  and  sometimes  difficulties  have  occurred  in 
passing  it  down  to  the  stricture. 

I  prefer  a  hollow  bougie  open  at  the  extremity,  into 
which  a  whalebone  stilet  is  introduced,  having  fixed 
on  its  end  two  pieces  of  silver  that  act  like  a  clasp, 
which  readily  holds  a  piece  of  caustic.  This  instru- 
ment is  used  in  this  city.  After  passing  it  down  to  the 
stricture,  the  stilet  is  pushed  forward,  and  the  caustic 
applied  directly  to  the  part.  If  any  difficulty  occurs  in 
the  introduction  of  the  instrument,  from  its  sides  hitch- 
ing in  the  lacunae  of  the  urethra,  a  small  solid  bougie 


TREATMENT  OF  STRICTURE.  297 

may  be  introduced  within  the  hollow  one,  and  in  this 
way  a  passage  may  be  made  for  it  down  to  the  stric- 
ture. 


Conditions  in  which  Caustic  is  imjwoper. 

When  we  consider  the  probable  condition  of  the 
urethra  subjected  to  the  influence  of  a  permanent  stric- 
ture, by  which  a  portion  of  the  canal  has  been  for  a 
long  time  very  much  contracted,  it  is  easy  to  conceive 
that  by  repeated  and  strong  eflforts  to  pass  urine  through 
the  contracted  portion,  the  parts  behind  the  stricture 
will  become  dilated,  and  the  urine  will  accumulate  in  a 
sort  of  pouch  formed  in  this  situation.  In  process  of 
time  the  sides  of  the  canal  at  this  point  will  become  so 
weakened  as  to  be  exposed  to  the  danger  of  rupture. 

When  caustic  is  applied  to  a  very  narrow  stricture, 
the  object  in  view  is  to  destroy  the  part,  with  the  ex- 
pectation of  a  slough  being  separated.  Before  this  can  be 
effected,  the  canal  in  the  vicinity  of  the  stricture  must 
become  inflamed  and  thickened,  and  during  the  process, 
the  urethra  at  this  part  may  be  almost  entirely  ^closed. 
Under  these  circumstances,  very  great  difficulty  is  ex- 
perienced in  discharging  the  urine,  and  I  have  known  an 
almost  total  retention  to  continue  for  one  or  two  days. 
When  a  slough  is  detached,  a  slight  increase  is  ob- 
served in  the  size  of  the  stream  of  urine,  and  the  risk 
of  closure  of  the  urethra  by  subsequent  applications  is 
diminished.  ^ 

But  it  may  happen,  that  the  application  of  caustic 
may  produce  a  complete  obstruction  in  the  passage. 
The  efforts  of  the  patient  to  discharge  urine  may  be  so 

38 


298  TREATMENT  OF  STRICTURE. 

violent  that  the  dilated  and  weakened  urethra,  behind 
the  stricture,  may  actually  burst.  The  urine  may  be  ex- 
tensively diffused  through  the  adjacent  cellular  texture 
producing  the  most  disastrous  effects. 


CASE  XXIV. 

Rupture  of  the  Urethra  from  Caustic. 

While  I  was  one  of  the  surgeons  of  the  Almshouse 
hospital,  a  poor  man  came  under  my  care  aflected  with 
stricture  of  the  urethra.  It  was  situated  some  distance 
anterior  to  the  bulb,  and  there  was  an  evident  enlarge- 
ment of  the  canal  behind  the  stricture.  The  treatment 
was  commenced  b}^  the  application  of  lunar  caustic  to 
the  stricture.  Soon  after  this, probably  within  forty-eight 
hours  from  the  application,  while  I  was  passing  through 
the  ward,  my  attention  was  called  to  the  patient.  My 
feelinors  were  shocked  when  I  discovered  that  the  ure- 
thra  had  given  way  behind  the  stricture,  and  urine  was 
extensively  effused  through  the  cellular  membrane  of 
the  penis,  scrotum,  about  the  thighs,  and  above  the 
pubis.  The  consequence  was  inflammation  and  morti- 
fication, which  terminated  in  the  death  of  the  patient. 


The  termination  of  this  case  caused  me  great  un- 
easiness, inasmuch  as  the  caustic  had  been  applied  under 
my  direction,  and  as  I  had  reason  to  fear,  that  it  had  an 
agency  in  producing  the  rupture  of  the  urethra. 
**  Such  an  accident  might  have  occurred  without  any 
surgical  interference,  as  will  be  shown  in  the  sequel. 
Yet  such  a  case  could  not  fail  to  make  a  deep  impres- 


TREATMENT  OF  STRICTURE.  299 

sion  on  any  practitioner,  whose  mind  was  imbued  with 
a  just  sense  of  the  responsibihty  resting  upon  him, 
when  the  life  of  a  fellow  being  is  placed  in  his  hands. 
It  has  fixed  my  determination  never  again  to  apply 
caustic  to  a  stricture  under  such  circumstances.  I  have 
considered  it  a  duty  to  state  the  case  honestly,  as  an 
instance  of  injudicious  practice.  It  is  the  part  of  hu- 
manity to  err.  I  have  long  thought,  that  if  medical 
men  were  careful  to  relate  to  the  profession  at  large,  i 
their  failures  in  practice,  with  the  reflections  and  con- 
clusions derived  from  them,  it  would  greatly  promote 
the  common  good.  It  would  aid  in  forming  a  medical 
chart  in  a  dangerous  navigation,  upon  which  would  be 
discovered  rocks  and  shoals,  which  v/ould  prove  of  vast 
importance  to  subsequent  navigators. 

Books  abounding  with  successful  results  of  practice 
are  numerous,  and  I  have  sometimes  thought,  that  some 
of  them  proved  too  much.  They  have  appeared  calcu- 
lated to  lead  the  sanguine  and  inexperienced  minds  of 
youth  into  a  belief,  that  they  had  only  to  go  and  do 
likewise;  while  a  moderate  acquaintance  with  the 
realities  of  medical  life,  must  soon  teach  some  im- 
portant and  painful  lessons. 

If  a  medical  man  toward  the  close  of  a  long  pro- 
fessional life  spent  in  observing  disease,  would  write  a 
little  book,  composed  entirely  of  a  detail  of  his  unsuc- 
cessful cases,  he  would  confer  a  lasting  benefit  on  man- 
kind. 


Another  condition  of  the  urethra  sometimes  occurs 
as  a  result  of  a  small  and  permanent  stricture,  which, 
if  I  remember  rightly,  has  been  described  bv  some  En<T- 


300  TREATMENT  OF  STRICTURE. 

lish  surgeon.  Its  existence  is  made  known  by  the  form- 
ation of  a  tumour  situated  in  the  perineum,  about  the  size 
of  a  common  orange  when  spht  in  half.  It  would  seem 
to  be  formed  by  distension,  combined  with  the  ulcera- 
tive process.  Its  sides  or  walls  are  measureably  de- 
fended from  immediate  danger  of  rupture;  yet  not 
sufficiently  so  to  protect  the  patient  from  a  risk  of  such 
consequences,  before  the  absorbents  have  formed  an 
opening  through  the  integuments,  and  established  an 
outlet  for  the  urine  by  a  fistulous  opening  in  the  peri- 
neum. 

An  example  of  this  form  of  disease,  once  occurred  to 
me  in  the  Almshouse  Hospital.  The  patient  had  an  old 
stricture,  with  a  tumour  of  this  description  in  the  peri- 
neum. He  was  affected  with  complete  retention  of 
urine.  The  poor  fellow  suffered  extreme  pain,  and  every 
effort  to  pass  the  catheter  failed.  My  colleague,  Dr. 
Hewson,  and  myself,  concluded  to  make  an  outlet  for 
the  urine  by  an  incision. 

The  patient  was  placed  on  a  table,  and  I  made  a 
bold  incision  into  the  tumour,  and  gave  free  vent  to  the 
accumulated  urine,  to  his  great  relief.  I  now^  attempted 
to  complete  the  operation,  by  dividing  the  stricture  by 
incision,  and  passing  a  catheter  through  the  penis  into 
the  bladder.  But  such  was  the  extreme  restlessness  and 
resistance  of  the  patient,  that  it  appeared  almost  im- 
possible to  carry  out  the  operation  at  this  time.  My 
colleague  joined  me  in  giving  place  to  our  more  tender 
feelings,  and  we  allowed  the  poor  wTetch  to  escape 
from  the  table.  We  felt  well  assured  that  he  was  re- 
lieved from  present  pain  and  danger,  and  hoped  that  at 
some  more  propitious  period  he  might  receive,  perhaps 
from  other  hands,  the  benefits  of  an  operation  for  radi- 
cal cure. 


TREATMENT  OF  STRICTURE.  301 

In  such  a  case  as  the  preceding,  I  should  also  con- 
sider the  application  of  caustic  to  the  stricture  equally 
objectionable. 


Rupture  cf  the  Urethra^  and  Effusion  of  Urine  into  the 

Cellular  Texture, 

It  has  been  previously  stated,  that  in  some  bad  cases 
of  stricture,  the  spontaneous  efforts  of  the  patient  to 
discharge  his  urine,  have  proved  sufficient  to  rupture 
the  urethra  behind  the  stricture,  and  to  give  rise  to  dan- 
gerous symptoms  from  the  effusion  of  urine. 

I  have  witnessed  a  few  of  these  cases,  and  have  found 
that  if  the  effusion  extends  above  the  pubis,  and  about 
the  groins  and  thighs,  that  the  death  of  the  patient  may 
be  expected,  from  the  violence  of  the  constitutional 
symptoms. 

In  this  accident  we  have  an  illustration  of  a  law  of 
the  human  economy,  that  when  urine  is  effused  into  the 
cellular  tissue,  it  will  cause  erysipelatous  inflammation 
and  mortification  of  the  parts  subjected  to  its  action. 
It  is  also  known,  that  the  injection  of  wine  into  the 
same  membrane  will  produce  similar  effects.  Hence  the 
accidents  which  have  arisen  in  attempts  at  the  radical 
cure  of  hydrocele. 

When  the  mortification  is  confined  within  the  limits 
of  the  scrotum,  the  patient  may  escape  with  his  life, 
being  subjected  to  the  inconvenience  of  a  fistula  in 
perinco. 

An  instance  of  this  kind  fell  under  my  observation 


302  TREATMENT  OF  STRICTURE. 

a  few  years  ago,  in  the  practice  of  my  friend  Dr.  C. 
D.  Meigs,  who  called  me  in  consultation.  The  patient 
was  affected  with  stricture;  a  rupture  of  the  urethra 
occurred  behind  the  stricture;  urine  was  effused;  and 
mortification  and  sloughing  of  the  scrotum,  and  about 
the  perineum,  took  place. 

I  lately  inquired  of  Dr.  Meigs,  if  he  could  give  me  an 
account  of  the  present  state  of  the  case.  He  informed 
me,  that  the  patient  recovered  from  the  immediate  ef- 
fects of  the  accident,  but  that  he  had  lost  sight  of  him  for 
several  years.  I  presume  that  a  fistula  in  perineo  still 
exists,  unless  he  has  been  subjected  to  appropriate 
treatment. 

A  case  most  threatening  in  its  character,  yet  ulti- 
mately successful  in  its  termination,  came  under  my 
notice  some  months  past,  in  consultation  with  Drs.  G. 
M'Clellan,  Pattison,  and  Hewson.  The  patient  had  suf- 
fered from  a  stricture  for  some  years.  Dr.  M'Clellan 
had  been  called  to  him  in  an  attack  of  complete  re- 
tention. The  urethra  gave  way  behind  the  stricture, 
and  urine  was  extensively  effused  into  the  cellular 
membrane.  It  had  evidently  extended  beyond  the  scro- 
tum, and  there  was  a  tumefied  state  of  the  skin  just 
above  the  pubis. 

It  was  ao-reed  in  consultation  that  Dr.  M'C.  should 
make  a  free  incision  into  the  integuments  about  the 
lower  part  of  the  scrotum,  so  as  to  allow  of  the  escape 
of  urine,  and  the  separation  of  sloughs.  The  case 
was  suspended  in  great  jeopardy  for  many  days,  dur- 
ing which  time  alarming  hemorrhage  took  place  from 
the  sloughing  parts,  which  seemed  to  be  arrested 
by  the  application  of  the  Kreosote  wash.  A  tonic 
course  of  treatment,  with  a  generous  diet  to  aid  the 


TREATMENT  OF  STRICTURE. 


303 


system  in  its  restorative  efforts,  was  most  diligently 
pursued;  and  the  patient  finally  recovered  under  the 
care  of  Dr.  M'Clellan. 


It  has  been  established  as  a  general  rule,  that  the 
effusion  of  urine  into  the  cellular  texture  of  the  scro- 
tum, will  produce  the  death  of  the  parts  subjected  to  its 
action.  The  following  case,  which  is  extraordinary  in 
its  character,  is  introduced  as  an  exception  to  the  rule. 
The  case  occurred  in  the  practice  of  my  friend  Dr. 
Gebhard,  who  kindly  furnished  me  with  a  full  detail 
of  it,  from  which  the  following  summary  has  been 
formed. 

CASE  XXV. 

Ruptured  Urethra — Effusion  witJiout  Gangrene. 

1  was  called  in  consultation  with  Dr.  Gebhard,  in  the 
winter  of  1819 — 20,  to  see  a  little  boy  aged  seven 
years.  From  the  age  of  nine  months,  the  child  had  been 
afflicted  severely  with  disease,  which  I  had  no  doubt 
was  produced  by  calculi  in  the  bladder.  Dr.  Gebhard 
had  attended  him  on  several  occasions  within  the  last 
eighteen  months,  with  violent  paroxysms  resembling 
fits  of  the  stone.  On  the  day  preceding  my  visit,  the 
Dr.  had  been  called  to  visit  him  in  one  of  his  usual 
attacks.  On  his  visit  the  next  morning,  he  found  the 
scrotum  uncommonly  enlarged,  tense,  and  diaphonous. 
The  parts  were  punctured  very  freely  with  a  lancet, 
and  urine  flowed  freely  through  the  punctures. 

My  attendance  was  now  requested.  We  continued 
to  watch  the  case  with  much  solicitude  for  many  days. 


304  TREATMENT  OP  STRICTURE. 

In  the  progress  of  the  disease,  the  constitutional  symp-- 
toms  were  very  severe,  and  the  danger  of  the  Httle 
patient  extreme.  The  tongue  was  dry  and  dark,  and 
the  pulse  was  frequent  and  feeble.  The  effusion  ex- 
tended above  the  pubis,  and  down  the  thighs.  The  skin 
was  tense,  and  a  moderate  blush  from  inflammation 
was  perceptible  over  the  elevated  surflice.  Mortifica- 
tion did  not  take  place  at  any  point.  The  bladder  was 
relieved  from  pain  and  distension,  urine  flowed  through 
the  punctures  in  the  perineum  and  scrotum,  and  occa- 
sionally a  portion  was  discharged  through  the  penis* 

There  was  no  doubt  that  the  effusion  arose  from  a 
rupture  of  the  urethra.  About  the  tenth  and  eleventh 
days  from  the  occurrence  of  the  effusion,  a  striking  im- 
provement in  his  condition  occurred.  The  tongue  be- 
came moist,  and  of  a  more  natural  colour,  the  pulse 
improved,  his  restlessness  and  delirium  subsided,  and 
he  began  to  have  a  desire  for  food.  The  inflammation 
and  tumefaction  of  the  scrotum  and  adjacent  parts  had 
greatly  abated;  and  though  he  was  extremely  feeble, 
his  strength  gradually  improved  under  a  nutritious  diet, 
and  in  about  a  month  from  his  attack  he  was  restored 
to  his  usual  strength. 

The  urine  was  discharged  more  copiously  from  se- 
veral fistulous  openings  about  the  perineum  than  by  the 
urethra. 

These  fistulae  gradually  diminished  in  size  and  num- 
ber, until  but  one  remained,  which  assumed  a  perma- 
nent character. 

Rem-arks. 

The  history  of  this  case  is  unusually  interesting.  I 
presume  the  original  cause  of  the  rupture  may  be  re- 
ferred to  a  small  calculus,  which  in  the  first  instance 
blocked  up  the  urethra. 


-  FISTULA  IN  PERINEO.  305 

But  the  fact  of  such  extensive  effusion  of  urine,  with- 
out mortification,  is  worthy  of  remark.  Inflammation 
occurred,  but  it  was  destitute  of  any  mahgnant  cha- 
racter. May  not  this  circumstance  be  rationally  attri- 
buted to  the  difference  in  the  quality  of  the  urine, 
between  the  adult  and  the  child.  In  the  former,  when 
brought  in  contact  with  the  cellular  membrane,  it  is 
found  to  be  an  acrid,  irritating  fluid,  spreading  death 
and  destruction  in  its  course;  while  in  the  infant  or 
child,  its  qualities  are  so  bland  as  only  to  produce 
healthy  inflammation. 


SECTION  II. 


FISTULA  IN  PERINEO. 


Having  alluded  to  some  of  the  causes  which  produce 
fistulous  openings  in  the  perineum,  I  shall  briefly  detail 
the  result  of  my  experience  in  the  treatment  of  these 
cases. 

Although  this  disease  is  not  dangerous,  yet  it  is  ex- 
tremely inconvenient  and  disgusting.  Instead  of  the 
urine  taking  its  natural  course  through  the  urethra,  it 
is  discharged  through  the  fistulous  opening.  The  pa- 
tient is  obliged,  when  called  upon  to  pass  urine,  to 
retire  to  the  privy,  and  place  himself  in  the  position 
required  for  an  alvine  discharge,  or  else  be  subjected 
to  the  filthy  dilemma  of  having  his  shirt  and  small- 
clothes constantly  wet. 

The  indications  for  radical  cure  in  these  cases  are 
clear  and  simple;  and  may  be  britfly  defined. 

3d 


306  FISTULA  IN  PERINEO.  , 

The  first  consists  in  the  removal  of  the  stricture 
which  lies  anterior  to  the  fistulous  opening.  This  may 
be  accomplished  by  the  liberal  use  of  caustic,  remem- 
bering that  as  the  urine  has  a  free  outlet  through  the 
fistulous  opening,  there  is  nothing  to  fear  from  its  ap- 
plication. 

There  can  be  no  risk  of  rupture  of  the  urethra  behind 
the  stricture,  inasmuch  as  an  opening  already  exists. 

Having  destroyed  the  stricture,  and  established  the 
route  to  the  bladder,  the  second  indication  is  accom- 
plished by  passing  a  succession  of  catheters  into  the 
bladder,  and  constantly  retaining  them  in  their  position, 
so  that  not  a  single  drop  of  urine  shall  be  permitted 
to  pass  through  the  fistulous  opening. 

Having  removed  the  urine,  the  primary  source  of 
irritation,  from  the  sinus;  the  third  indication  consists 
in  breaking  down  its  hardened  walls,  by  the  applica- 
tion of  caustic. 

This  object  being  accomplished,  the  final  indication 
consists  in  approximating  the  sides  of  the  fistula,  by 
adhesive  strips.  Healthy  granulations  arise  through  the 
fistula,  and  its  sides  are  brought  into  contact.  In  this 
way  the  opening  is  closed,  the  parts  become  consoli- 
dated, and  the  cure  is  radical. 

,   In  illustration  of  these  views,  the  following  cases  are 
presented. 


CASE  XXVI. 

One  of  the  worst  cases  of  this  disease,  that  I  ever 
witnessed,  came  under  my  notice  in  the  summer  of 


•  FISTULA  IN  PERINEO.  307 

1820.  The  patient  was  a  gentleman  from  the  West 
Indies,  who  came  to  this  country  to  seek  the  advice  of 
Dr.  Physick.  Drs.  Gibson,  Horner,  and  myself  were 
associated  with  him  in  consultation.  The  opening  in 
the  perineum  was  so  large,  as  almost  to  foreclose  the 
hope  of  a  cure.  The  stricture  had  been  removed  at 
home,  and  a  catheter  could  be  passed  into  the  bladder. 
Dr.  Physick,  from  his  extensive  experience  in  such 
cases,  was  more  sanguine  of  success  in  the  case,  than 
were  his  associates.  I  can  speak,  at  least,  for  myself. 
The  event  justified  the  correctness  of  his  judgment. 
The  walls  of  the  sinus  were  broken  down  by  the  caus- 
tic, w  hich  was  freely  employed,  while  the  catheter  w^as 
steadily  retained  in  the  bladder.  Strips  of  adhesive 
plaster  completed  the  cure. 


CASE  XXVII. 


An  elderly  man  came  under  my  notice  in  the  surgi- 
cal ward,  of  the  Almshouse  Hospital,  with  fistula  in 
perineo,  of  seven  years  duration,  attended  with  a  per- 
manent stricture  of  the  urethra. 

It  was  a  remarkably  fine  case  for  testing  the  efficacy 
of  appropriate  practice,  and  I  felt  particularly  pleased 
in  presenting  it  to  the  students  in  attendance.  The 
indications  to  be  fulfilled  were  explained,  and  an  oppor- 
tunity was  afforded  for  the  class  to  watch  the  progress 
of  the  case.  The  caustic  was  applied  freely  and  fre- 
quently to  the  stricture.  No  hemorrhage  ensued,  and  I 
am  inclined  to  believe,  that  in  old  strictures,  where  the 


308  FISTULA  IN  PERINEO. 

sides  of  the  canal  are  indurated,  it  is  less  to  be  feared 
than  in  recent  cases. 

In  due  course  of  time,  the  stricture  was  so  far  re- 
moved that  a  catheter  could  be  passed  forward  into  the 
bladder,  in  which  situation  it  was  retained.  The 
hardened  walls  of  the  fistula  were  now  attacked  with 
caustic,  and  soon  destroyed.  Healthy  inflammation 
was  followed  by  granulations  which  filled  up  the  cavity; 
the  edges  were  approximated  by  adhesive  strips;  cica- 
trization ensued,  and  the  cure  was  eflfected. 


Soon  after  this  I  had  a  very  similar  case  in  a  sailor, 
in  the  venereal  ward  of  the  Pennsylvania  Hospital. 
The  fistula  had  existed  for  about  two  years  and  a  half. 
The  same  principles  of  practice  were  applied  with  equal 
success. 


CHAPTER  IV. 

TIC  DOLOUREUX  OF  THE  URINARY  BLADDER. 

The  experience  of  the  medical  profession  is  greatly 
enlarged  on  that  painful  and  paroxysmal  affection  of  the 
nerves,  denominated  tic  doloureux.  A  few  years  ago, 
this  term  was  almost  exclusively  applied  to  a  severely 
painful  affection  of  the  supra  and  infra  orbital  nerves; 
the  disease  being  always  associated  in  the  mind  with  a 
facial  locality.  More  recent  investigations  have  shown 
that  this  affection  may  exist  in  various  parts  of  the 
body.  Under  the  generic  term  of  neuralgia,  we  have 
a  class  of  diseases  which  excite  much  attention  at  the 
present  time. 

I  have  known  instances  of  great  suffering  in  the 
urinary  organs,  from  this  form  of  disease.  Its  attacks 
are  violent,  and  bear  so  exact  a  resemblance  to  the 
paroxysms  induced  by  the  presence  of  calculus  in  the 
bladder,  that  it  is  impossible  to  decide  between  the  two 
conditions.  In  these  cases  the  bladder  has  been  fre- 
quently sounded  without  detecting  a  stone,  and  tlie 
subsequent  progress  of  the  cases  induced  the  belief 
that  none  had  existed. 

I  will  briefly  state  the  result  of  my  observations  on 
this  subject. 


310  TIC  DOLOUREUX  OF  THE 


CASE  XXVIII. 

Some  years  ago,  a  young  man  came  to  this  city  to 
{^•:>nsult  Dr.  Physick;  he  was  affected  with  the  usual 
symptoms  of  a  calculus  in  the  bladder. 

Dr.  Physick  did  not  examine  him  particularly,  but 
recommended  him  to  my  care,  as  a  proper  patient  for 
the  Pennsylvania  Hospital,  where  he  might  undergo 
the  operation  of  lithotomy. 

After  his  admission,  on  attempting  to  sound  him,  he 
complained  very  much  of  exquisite  pain;  the  parts  were 
irritable  to  an  unusual  degree.  No  stone  was  disco- 
vered by  the  examination.  My  colleagues  joined  me  in 
efforts  to  discover  a  stone  by  the  usual  means,  but 
without  success.  The  patient  suffered  from  agonizing 
pain,  which  attacked  him  in  frequent  paroxysms,  and 
resembled  exactly  "  fits  of  the  stone."  After  remaining 
for  a  considerable  length  of  time  in  the  Hospital,  and 
undergoing  a  variety  of  treatment,  he  was  discharged 
without  being  materially  benefited,  and  returned  to  his 
friends.     The  final  issue  of  the  case  I  never  heard. 


CASE  XXIX. 

I  was  called  to  visit  a  middle  aged  married  lady  in 
this  city,  who  was  affected  with  similar  symptoms.  She 
was  naturally  of  a  very  delicate  constitution,  and  of  a 
nervous  temperament,  and  had  borne  a  number  of 
children. 


URINARY  BLADDER.  311 

She  was  attacked  with  this  affection  of  the  bladder, 
soon  after  the  birth  of  a  child.  Her  paroxysms  of  pain 
were  violent,  and  resembled  exactly  the  symptoms  pro- 
duced by  stone.  She  was  repeatedly  sounded,  but  no  cal- 
culus was  ever  discovered.  Aftersuffering  intensely  from 
these  paroxysms  for  several  months,  her  symptoms  dis- 
appeared, and  siie  was  restored  to  her  usual  health. 


I  am  aware  that  the  above  cases  do  not  afford  con- 
clusive evidence  of  the  existence  of  this  disease.  Pa- 
tients may  labour  under  stone  in  the  bladder,  and  may 
be  repeatedly  sounded,  before  it  is  discovered.  Yet  the 
examination  may  ultimately  prove  successful.  The  cal- 
culus may  be  removed  by  an  operation,  and  the  patient 
be  finally  restored  to  health.  A  case  of  this  kind  once 
occurred  in  my  own  practice. 

It  may  also  happen  that  a  calculus  will  become  en- 
cysted, and  in  this  way  the  symptoms  will  disappear, 
leaving  the  impression  on  the  mind  of  the  surgeon,  that 
the  symptoms  arose  from  some  other  cause. 

The  question  can  only  be  settled  by  post  mortem 
examination,  and  an  opportunity  has  been  furnished 
me  of  testing  it  by  this  method.  I  have  also  the  plea- 
sure of  adding  Dr.  Physick's  testimony  to  my  own,  on 
this  point.  In  conversation  with  him  some  years  since 
on  this  subject,  he  informed  me,  that  he  had  a  gentle- 
man under  his  care,  who  was  affected  with  clearly 
marked  symptoms  of  stone  in  the  bladder.  Dr.  P. 
sounded  him  frequently  without  being  able  to  discover 
a  calculus.  The  patient  finally  died.  On  examination 
after  death,  the  bladder  was  found  to  be  healthy,  and  no 
stone  could  be  found. 

After  stating  this  case,  the  Doctor  very  emphatically 


312  -TIC  DOLOUREUX  OF  THE 

said,  "  The  disease  is  tic  doloureux  of  the  bladder."  The 
definition  appeared  truly  concise  and  appropriate,  and 
1  have  therefore  adopted  it. 

Since  that  period  a  case  has  fallen  under  my  own 
observation,  which  is  very  conclusive,  and  has  con- 
firmed me  in  the  opinion,  that  the  urinary  bladder  is  the 
subject  of  an  extremely  painful  nervous  affection,  which 
cannot  be  designated  by  a  term  more  appropriate  than 
that  which  is  here  adopted. 

The  following  case  is  a  fair  example  of  this  disease. 


CASE  XXX. 

Tic  Doloureux  of  the  Bladder. 

1th  mo.  4th,  1822.  Died  this  morning  in  the  Pennsyl- 
vania Hospital,  R.  N.,  a  young  woman  who  has  been 
an  inmate  of  the  institution  for  several  years,  during 
which  time  her  sufferings  have  been  extreme. 

She  was  afflicted  with  violent  paroxysms  of  pain, 
exactly  resembling  fits  of  the  stone.  She  also  appeared 
to  labour  under  disease  of  the  uterus;  had  obstinate 
amenorrhoea;  sometimes  a  vomiting  of  blood. 

Various  expedients  were  tried  for  her  relief — in  fact, 
it  seemed  as  if  all  the  medical  and  surgical  skill  of  the 
institution  was  fairly  exhausted  on  this  afflicted,  but 
patient  sufferer!  She  was  placed  under  the  care  of  phy- 
sicians as  well  as  surgeons.  Among  the  palliative  reme- 
dies in  her  paroxysms  of  agony,  for  so  they  may  be 
called,  venesection  and  opiates  afforded  most  relief. 
Toward  the  conclusion  of  her  disease,  she  had  two 


URINARY  BLADDER.  313 

attacks  of  dysentery,  and  was  happily  released  from 
her  troubles  in  the  last  attack. 

The  symptoms  of  stone  in  the  bladder  were  so 
strongly  marked  in  this  case,  that  the  patient  was  often 
sounded.  I  beheve  all  the  surgeons  searched  for  stone. 
I  did,  repeatedly,  and  even  proposed  dilating  the  ure- 
thra, with  the  sponge-tent,  in  order  to  introduce  the 
finger  into  the  bladder. 

To  conclude,  it  may  be  said,  that  I  never  witnessed 
a  case  of  more  severe  and  protracted  suffering,  nor  one 
in  which  the  symptoms  of  calculus  in  the  bladder  ap- 
peared to  be  more  clearly  marked.  And  now,  behold 
the  humiliating  evidence  of  the  fallibility  of  human 
judgment,  as  displayed  in  the  dissection  of  R.  N. 

Examination — Post  mortem. 

The  bladder  contained  no  stone,  and,  Avith  the  kid- 
neys and  ureters,  presented  a  perfectly  natural  appear- 
ance! The  stomach,  liver,  lungs,  and  uterus,  all  healthy! 
The  intestines  gave  some  signs  of  recent  disease.  The 
pancreas  was  indurated.  The  muscles  red  and  firm. 
There  was  a  considerable  amount  of  fat  over  the  abdo- 
men, and  on  the  omentum,  although  the  patient  had  a 
very  bloodless  aspect. 

I  was  informed  by  Dr.  John  Rhea  Barton,  who  was 
present  at  the  dissection  with  Dr.  Price  and  others,  that 
if  he  had  been  called  upon,  in  the  dissecting  room,  to 
select  a  subject  whose  viscera,  generally,  presented  a 
sound  and  natural  appearance  after  death,  he  could 
scarcely  have  selected  one  better  adapted  to  the  purpose 
than  the  mortal  remains  of  the  deeply  afflicted  R.  N. 

40 


CHAPTER  V. 


NEPHRITIS. 


The  occurrence  of  nephritic  affections,  especially  in 
gouty  patients,  is  familiar  to  most  medical  men,  and  in 
the  usual  course  of  practice,  cases  of  this  kind  require 
their  care. 

The  seat  of  this  painful  affection  is  primarily  in  the 
kidneys,  and  from  thence  is  propagated  to  contiguous 
parts.  It  is  caused  by  the  formation  of  small  calculi  in 
the  kidney.  Should  one  of  these  pass  through  the  ure- 
ter into  the  bladder,  a  train  of  most  painful  symptoms 
ensue,  often  causing  great  alarm  to  the  patient  and  his 
friends;  but  seldom  being  really  dangerous. 

The  disease  is  generally  marked  by  some  peculiari- 
ties which  enable  the  practitioner  to  form  a  correct 
diagnosis,  by  referring  to  the  anatomical  and  relative 
position  of  the  parts.  The  pain  is  referred  to  the  hy- 
pogastric region,  having  an  obliquity  in  its  course,  cor- 
responding to  the  passage  of  the  ureter  from  the  kid- 
ney to  the  bladder.  The  testis  on  the  affected  side  is 
frequently  retracted  and  painful.  This  fact  admits  of  a 
ready  explanation,  when  it  is  recollected,  that  the  ure- 
ters and  vasa  deferentia  decussate  each  other  in  the 
neighbourhood  of  the  part  where  the  former  enter  the 
bladder;  hence,  irritation  and  pain  in  the  one,  can  readily 
be  propagated  to  the  other.  The  bladder  and  urethra, 
like  continuous  hnks  in  the  chain,  may  experience  the 


NEPHRITIS.  315 

effects  of  morbid  association.  The  whole  nervous  sys- 
tem may  be  brought  into  sympathy.  That  important 
viscus,  the  stomach,  may  largely  participate,  and  be- 
come involved  even  in  convulsive  action,  manifested  by 
severe  retchings  and  vomiting.  At  the  very  onset  of  the 
disease,  the  patient  is  often  instantaneously  affected 
with  great  prostration  of  system,  pallor  and  coldness 
of  surface,  and  feebleness  of  circulation.  I  have  known 
syncope  to  take  place  at  the  accession  of  the  attack. 
In  illustration  I  will  state  a  case. 


CASE  XXXI. 


A  merchant  of  middle  age,  a  strong,  well-built  man, 
of  temperate  habits,  and  possessing  considerable  firm- 
ness of  disposition,  went  to  bed  in  usual  health.  He 
awoke  in  the  night,  and  felt  a  disposition  to  urinate. 
He  rose  from  bed  for  the  purpose,  and  was  instantly 
seized  with  such  intense  pain,  that  before  his  w  ife  could 
assist  him,  he  sunk  on  the  floor  in  a  state  of  syncope. 
The  alarm  of  his  family  can  be  easily  imagined.  I  saw 
him  shortly  after  the  attack.  His  skin  was  cold;  his 
pulse  very  feeble;  and  his  pain  was  agonizing.  Under 
proper  treatment  he  speedily  recovered. 


In  the  early  part  of  my  practice,  I  once  saw  this  dis- 
ease assume  an  intermittent  form.  As  the  case  was  un- 
usual in  its  character,  I  will  detail  it  from  my  note 
book. 


316  NEPHRITIS. 


CASE  XXXII. 

In  the  winter  of  1806, 1  was  called  one  night  from 
my  bed,  to  visit  J.  R.,  a  very  respectable  man,  who 
had  exchanged  the  active  life  of  a  farmer  for  the  more 
easy  situation  of  a  citizen.     I  found  him  sitting  in  a 
chair  before  the  fire.    The  pain  corresponded  with  the 
course  of  the  ureter.     The  testis  participated.  He  had 
a  scalding  sensation  when  he  attempted  to  pass  water, 
accompanied  with  tenesmus,  nausea,  and  vomiting.  The 
case  was  clearly  marked,  and  depended  upon  the  pas- 
satre  of  a  calculus  through  the  ureter.  I  directed  a  dose 
of  calomel  and  opium,  and  was  about  to  put  other  plans 
in  operation,  when,  before  even  taking  the  medicine, 
he  said  he  felt  relieved,  and  that  he  thought  something 
had  passed  from  "  a  small  passage  into  a  larger  one." 

I  now  obtained  from  him  a  clear  history  of  the  case. 
His  first  attack  was  some  days  before  I  saw  him;  it 
took  place  while  on  a  journey  from  New  England  to 
Philadelphia.  It  came  on  about  3  o'clock  in  the  morn- 
ing and  lasted  about  two  hours.  It  had  recurred  regu- 
larly every  succeeding  night  since,  about  the  same  hour, 
and  its  duration  was  nearly  the  same.  When  the  attack 
commenced,  he  always  found  that  he  was  more  easy 
in  the  erect,  than  in  the  recumbent  posture;  and  it  was 
his  uniform  practice  to  rise  from  bed,  and  set  before 
the  fire  until  it  went  off.  At  the  time  he  sent  for  me, 
the  pain  was  more  violent  than  he  had  ever  before  ex- 
perienced.    This  proved  to  be  the  last  paroxysm. 

Nephritic  cases  are  often  sudden  in  their  accession, 
and  speedy  in  their  termination.     The  patient  is  in- 


NEPHRITIS.  •  317 

stantly  sensible  of  relief  when  the  calculus  falls  into  the 
bladder. 

I  have  met  with  some  cases  where  the  disease  as- 
sumed a  more  chronic  form,  confining  the  patient  to 
his  room  and  bed,  and  attended  with  inflammation  and 
fever.  It  would  seem  as  if  the  calculus  was  too  large 
readily  to  pass,  and  considerable  time  was  required  be- 
fore this  could  be  accomplished. 

Treatment. 

The  course  of  treatment  to  be  pursued  in  the  acute 
form  of  nephritis  is  worthy  of  close  consideration.  I 
feel  more  inclined  to  examine  this  part  of  the  subject, 
from  the  fact,  that  our  practice  is  these  cases  is  not 
uniform  and  settled.  I  believe  no  small  injury  may 
result  from  associations  formed  in  medical  minds,  which 
must  have  an  important  bearing  on  therapeutics.  Thus 
pain  and  inflammation  are  so  intimately  associated, 
that  it  seems  in  some  instances  impossible  to  dissever 
them.  Hence,  in  all  those  cases  of  acute  nephritis,  one 
of  the  first  indications  founded  upon  this  conclusion  is, 
the  free  use  of  the  lancet.  And  where  inflammation  is 
to  be  measured  by  intensity  of  pain,  it  may  be  free  in- 
deed. Let  us  now  advert  to  the  circumstances  which 
may  be  reasonably  supposed  to  attend  an  acute  attack 
of  this  disease.  I^et  us  take  the  case  of  the  merchant, 
who  at  the  very  onset  was  prostrated  by  syncope,  almost 
instantaneously,  on  the  floor  of  his  bed-chamber.  What 
caused  this  intense  pain?  was  it  not  the  passage  of  a 
hard  and  irregular  shaped  calculus  along  the  extremely 
sensitive  ureter?  Was  not  the  pain  suddenly  induced 
by  the  operation  of  a  mechanical  cause? 

That  inflammation  may  follow  as  a  consequence  of 


» 


318  .  NEPHRITIS. 

contusion,  or  lesion  of  parts,  is  a  principle  fully  un- 
derstood. But  that  it  should  be  coeval  with  the  inflic- 
tion of  the  injury,  is  utterly  at  variance  with  every 
principle  of  surgical  pathology.  Time  must  be  allowed 
for  the  injured  vessels  to  rally  their  energies,  and 
assume  those  peculiar  actions  which  constitute  inflam- 
mation. 

Does  the  state  of  the  system,  in  a  case  of  severe  ne- 
phritis at  its  commencement,  warrant  the  conclusion 
that  the  lancet  is  required?  Are  pallor  and  coldness  of 
surface,  with  a  very  feeble  state  of  the  circulation  sud- 
denly induced,  to  be  accepted  as  evidence  of  inflamma- 
tion? The  answer  is,  no — but  the  reverse — a  state  of 
prostration.  It  may  be  argued,  that  even  if  inflamma- 
tion does  not  exist,  free  bleeding  may  be  useful  in  order 
to  prevent  it. 

To  discuss  this  question,  would  at  present  be  out  of 
place;  were  it  entered  upon,  I  think  it  might  be  shown 
by  a  reference  to  practical  facts,  that  the  doctrine  of 
free  bleeding  as  a  prophylactic  for  inflammation,  is  far 
more  vulnerable  than  is  imagined.  I  regard  it  as  un- 
sound. Perhaps  at  a  proper  time,  an  opportunity  may 
be  offered  for  further  illustration. 

It  may  be  urged  that  patients  speedily  recover  after 
free  bleeding.  It  may  be  replied  with  equal  truth,  that 
they  speedily  recover  without  it.  The  violent  case  of 
the  merchant  was  a  striking  instance  in  point — he  did 
not  lose  one  drop  of  blood. 

I  have  long  since  established  it  as  a  medical  axiom, 
when  a  practitioner  can  achieve  his  object  by  a  resort 
to  safe,  yet  efficient  remedies,  without  drawing  largely 
on  the  constitutional  energies  of  his  patient,  it  is  wise 
to  pursue  the  former  course,  and  reserve  the  latter  for 


NEPHRITIS.  319 

those  emergencies  which  do  arise,  where  minor  consi- 
derations must  yield  to  the  one  all-absorbing  indication, 
the  rescue  of  the  patient  from  the  grasp  of  a  fatal  dis- 
ease. These  observations  may  be  regarded  as  a  digres- 
sion; but  they  are  felt  to  be  due  to  the  profession,  inas- 
much as  physicians,  as  well  as  surgeons,  are  deeply  inte- 
rested in  the  disease  now  under  consideration. 

The  primary  indications  of  treatment  in  acute  ne- 
phritis, are  the  following: — x\llay  pain  and  irritation  by 
the  use  of  opiates,  having  reference  at  the  same  time 
to  the  state  of  the  bowels.  If  they  should  be  confined, 
it  is  advisable  to  combine  some  purgative  with  the 
opiate.  I  often  combine  two  grains  of  opium  with  ten 
or  twelve  grains  of  calomel  made  into  pills.  Sometimes 
if  the  symptoms  are  very  urgent,  I  have  given  three 
grains  of  opium  with  the  calomel.  In  many  cases  I  find 
a  dose  of  castor  oil  with  laudanum,  to  answer  quite  as 
well  as  the  calomel.  Should  the  stomach  reject  medi- 
cine, I  resort  to  anodyne  injections,  preceded  by  laxa- 
tive enemata,  if  there  is  reason  to  suppose  the  rec- 
tum contains  feces.  When  we  consider  the  contiguity 
of  the  rectum  to  the  urinary  bladder,  it  is  easy  to 
understand  how  a  soothing  impression  made  on  the 
former,  will  be  speedily  propagated  to  the  latter.  Hence 
an  anodyne  injection  sometimes  acts  like  a  charm. 
Could  it  be  readily  obtained,  it  might  often  supersede 
the  exhibition  of  remedies  by  the  mouth. 

Another  indication  consists  in  restoring  heat  and 
action  to  the  surface,  and  particularly  the  lower  extre- 
mities. Thus  sinapisms  maybe  applied  advantageously. 
Immersion  of  the  feet  and  legs  in  warm,  or  rather  hot 
water,  to  which  either  mustard  or  coarse  salt  is  added. 
Spirituous  fomentations  to  the  abdomen  are  frequently 


320  NEPHRITIS. 

useful.  If  relief  is  not  procured,  a  warm  bath  would  be 
clearly  indicated.  These  means  seldom  fail  to  miti- 
gate the  violence  of  the  disease.  The  calculus  passes 
into  the  bladder,  and  full  relief  is  obtained.  When  the 
stomach  will  bear  mild  demulcent  drinks,  they  should 
be  freely  used.  Sometimes  before  a  resolution  of  the 
paroxysm,  reaction  takes  place,  and  fever  ensues;  then 
depletory  measures  are  indicated.  In  vigorous  subjects 
general  and  topical  bleeding  are  required.  In  subjects 
of  a  more  delicate  and  feeble  character,  cupping  or 
leeching  about  the  lumbar  vertebrae,  aided  by  laxatives, 
warm  bath,  and  injections,  may  prove  sufficient.  Some- 
times I  have  directed  large  quantities  of  tepid  flaxseed- 
tea  to  be  introduced  into  the  bowels,  to  act  upon  the 
principle  of  a  warm  bath  internally  applied.  Anodyne 
injections,  when  the  pain  is  severe,  are  particulary  pro- 
per. 

Among  the  internal  remedies,  the  spirits  of  turpen- 
tine may  be  noticed.  One  of  my  medical  friends  who 
has  been  severely  afflicted  with  nephritis,  has  great  con- 
fidence in  the  remedy.  When  he  feels  the  least  threat- 
ening of  an  attack,  such  as  uneasiness  and  slight  pain 
about  his  kidneys,  he  will  alight  from  his  carriage  before 
the  shop  of  any  apothecary,  and  take  twelve  drops  of 
spirits  of  turpentine  on  loaf  sugar,  with  decided  relief. 

Patients  liable  to  nephritis,  often  consult  their  phy- 
sicians relative  to  prophylactic  remedies.  To  enter 
fully  into  this  subject  would  lead  beyond  my  pre- 
scribed limits.  I  would  briefly  remark,  that  in  some 
instances  the  uva  ursi,  the  extra  soda  water,  and  the 
Saratoga  water,  appear  to  have  produced  a  very  salu- 
tary effect.  In  this  city,  the  scabious  tea  is  a  popular 
remedy.     It  has  derived  much  of  its  reputation  from 


NEPHRITIS.  321 

a  valuable  old  citizen  long  since  deceased,  ^^ho  was  in 
extensive  business  as  a  biscuit  baker.  He  was  severely 
afflicted  with  the  disease,  and  had  derived  such  relief 
from  the  scabious,  that  at  the  proper  season  to  gather 
the  plant,  he  was  in  the  practice  of  going  out  with  his 
work-people,  and  his  horse  and  cart,  in  order  to  collect 
it  in  the  fields  round  the  city.  Having  obtained  a  large 
supply,  he  always  kept  it  for  gratuitous  distribution, 
humanely  desiring  to  confer  that  relief  on  others,  which 
he  believed  he  had  himself  received  from  the  scabious. 


It  has  been  stated,  that  nephritic  affections,  depend- 
ing on  calculi  formed  in  the  kidney,  although  very  pain- 
ful, are  seldom  of  a  dangerous  character. 

It  now  remains  for  us  to  consider  another  morbid 
condition  of  this  organ,  by  which  its  structure  is  gra- 
dually altered,  and  the  death  of  the  patient  is  the  re- 
sult. 

The  following  cases  illustrate  this  singular  form  of 
disease. 


CASE  XXXIII. 

Irritable  Bladder  and  Urethra — Disorganization  of  the 

Kidney — Death . 

4th  mo.  10th,  1821.  B.  R.,  a  respectable  merchant, 
about  sixty  years  of  age,  had  long  been  subject  to 
gout,  and  had  lately  been  affected  with  much  depression 

41 


332  NEPHRITIS 

of  mind,  arising  from  a  failure  in  his  business.  For 
more  than  a  year  preceding  his  death,  he  had  suffered 
grievously  from  an  affection  of  the  urinary  organs.  He 
was  obliged  to  make  frequent  efforts  to  pass  small 
quantities  of  urine,  during  the  day  and  night.  His  ure- 
thra was  extremely  irritable,  and  the  most  careful  at- 
tempts to  introduce  the  catheter  caused  him  great  pain. 
I  at  one  time  suspected  the  presence  of  a  calculus,  but 
could  discover  nothing  by  sounding.  Sometimes  he 
had  retention  of  urine  requiring  the  use  of  the  ca- 
theter. 

Under  these  circumstances,  various  means  of  relief 
were  tried  without  any  salutary  effect.  His  strength 
gradually  failed,  his  complexion  assumed  a  sallow  hue, 
and  his  whole  aspect  exhibited  evidences  of  great 
bodily  suffering.  It  was  also  evident,  that  a  sensitive 
and  upright  mind  participated  largely  in  his  afflictions. 
For  several  weeks  before  his  death,  he  was  affected 
with  severe  muscular  spasms,  affecting  both  the  upper 
and  lower  extremities.  There  was  also  an  evident 
failure  in  his  mental  faculties  a  short  time  before  his 
death. 

Dissection, 

The  body  was  examined  by  my  friend  Dr.  Harlan. 

The  internal  surface  of  the  bladder  was  interspersed 
with  dark  spots,  curiously  intersected  by  whitish  bands, 
which  did  not  rise  above  the  surface  of  the  mucous 
membrane.  At  the  neck  of  the  bladder  around  the 
opening  of  the  urethra,  there  was  a  red  spot  about  the 
size  of  a  quarter  of  a  dollar. 

The  kidneys  were  unusually  small.     The  infundibula 


NEPHRITIS.  323 

of  the  left  kidney  were  very  large,  and  the  pelvis  of  the 
right  was  very  much  distended,  giving  the  idea  of  a 
stricture  in  the  ureter,  and  a  regurgitation  of  urine 
into  the  pelvis;  though  no  stricture  was  discovered. 

The  prostate  gland  presented  a  healthy  appearance. 
From  the  symptoms,  I  had  expected  to  find  great 
thickening  of  the  mucous  and  muscular  coats  of  the 
bladder. 

I  have  extracted  from  my  notes  the  following  case, 
which,  in  some  respects,  bears  a  strong  resemblance  to 
the  preceding. 


CASE  XXXIV. 

In  the  autumn  of  1809, 1  was  consulted  by  an  elderly 
and  highly  respectable  man,  from  Lancaster  county,  who 
came  to  this  city  seeking  relief  from  a  very  painful  dis- 
ease. He  had  been  for  a  long  time  affected  with  an 
irritable  bladder,  and  an  exquisitely  morbid  sensibility 
of  the  urethra,  such  as  I  had  never  seen  surpassed.  In 
his  attempts  to  pass  urine,  which  were  frequent,  he  com- 
plained of  severe  pain  and  scalding  in  the  canal,  parti- 
cularly towards  the  arch  of  the  pubis.  The  pain  ex- 
tended from  the  point  of  the  penis  inwards,  and  ho 
experienced  slight  uneasiness  about  the  neck  of  the 
bladder.  He  once  had  a  stricture,  but  this  had  been 
cured. 

I  sounded  him  for  stone,  examined  the  prostate,  but 
could  find  nothing  which  satisfactorily  explained  the 
symptoms.  He  was  under  my  care  for  many  weeks, 
and  a  variety  of  remedie?  were  tried.     His  complaint 


324  NEPHRITIS. 

was  palliated,  but  he  was  not  permanently  benefitted. 
He  used  opium,  hyosciamus,  stramonium,  colchicum, 
*kc.,  also,  emollient  injections  into  the  bladder.  He  re- 
turned home  for  a  while,  and  subsequently  came  back 
to  the  city,  and  placed  himself  under  the  care  of  seve- 
ral different  practitioners.  I  was  called  in  consultation 
with  one  of  them,  but,  as  on  other  occasions,  no  treat- 
ment successfully  reached  the  case.  He  returned  home, 
and  died. 

I  have  been  informed  by  one  of  his  friends,  that  he 
was  examined  after  death,  and  that  one  of  his  kidneys 
"was  nearly  wasted  away."  His  friend  was  not  a 
medical  man,  and  of  course  I  could  not  obtain  the  pre- 
cise information  which  I  desired.  The  symptoms  bore 
a  strong  resemblance  to  the  preceding  case,  and  I  pre- 
sume depended  on  the  same  cause. 


In  reflecting  on  these  cases,  which,  so  far  as  my  ob- 
servation extends,  are  of  an  unusual  character,  I  have 
arrived  at  the  conclusion;  that  if  I  should  again  meet 
with  a  case  of  extreme  sensitiveness  in  the  bladder  and 
urethra,  which  could  not  be  referred  to  any  obvious 
cause,  as  an  enlarged  state  of  the  prostate,  stricture  of 
the  urethra,  &c.,  and  which  differed  from  tic  doloureux 
of  the  bladder,  in  the  permanency  of  the  pain,  and  the 
absence  of  paroxysms,  I  should  refer  it  to  some  organic 
lesion  of  one  or  both  kidneys,  depending  on  a  gouty 
diathesis. 

Whether  this  disease  could  be  eradicated  by  any 
method  of  treatment,  pursued  in  the  early  stage,  I  am 
altogether  unable  to  determine  from  experience.  Per- 
haps the  application  of  setons,  or  perpetual  blisters  on 


NEPHRITIS.  325 

each  side  of  the  spine,  or  even  in  a  remote  situation, 
might  exercise  a  favourable  influence,  by  causing  a 
weaker  part  in  the  vicinity  of  the  affected  organ,  and 
thus  acting  on  the  principle  of  metastasis. 

The  remedies  adapted  to  the  treatment  of  gout, 
when  it  occurs  in  other  parts  of  the  body,  might  also 
deserve  a  trial. 


CONCLUSIOxN. 


My  observations  on  Strangulated  Hernia,  and  some 
of  the  Diseases  of  the  Urinary  Organs,  are  now  closed. 
It  will  be  perceived,  that  the  volume  is  plain  and  prac- 
tical in  its  character.  It  is  said,  every  man  who  thinks 
theorises.  Perhaps,  in  one  sense,  this  may  be  true.  It 
is  very  important,  however,  that  theories  should  be 
based  on  a  solid  foundation.  I  hold  myself  still  to  be 
a  student  in  the  school  of  practical  observation,  and  am 
frequently  picking  up  useful  knowledge  in  passing 
along,  and  am  gaining  much  information  from  others. 
I  have  found  out  too,  that  it  is  an  easy  matter  for  an 
ingenious  man  to  tell  what  he  thinks,  and  sometimes 
very  useful  hints  are  to  be  obtained  from  the  thoughts 
of  others.  Still  it  must  be  acknowledged  that  more  is 
to  be  learned  when  a  man,  whose  accuracy  is  to  be 
depended  on  tells  what  he  really  knows.  In  common 
with  the  elder  members  of  the  profession,  the  writer 
has  seen  beautiful  theories  erected — the  builder  has  ad- 
mired the  work  of  his  own  hands — a  few  simple  facts 
have  undermined  the  foundation — the  edifice  has  tot- 
tered, and  fallen  into  ruins.  It  is  my  earnest  desire  to 
avoid  every  just  cause  for  the  suspicion  of  vanity  and 
egotism.  In  putting  forth  this  book,  the  writer  could 
not  gain  his  own  consent  to  send  it  out,  w'ith  abun- 
dance of  apologies  for  its  numerous  imperfections, 
while  at  the  same  time  he  did  not  believe  such  to  be  the 
fact. 


CONCLUSION. 


327 


Still  he  is  fully  aware  that  an  author  may  view  his 
first  book,  a  little  like  a  parent  views  an  only  child. 
He  may  see  beauties  where  a  disinterested  person 
could  not  discover  any  thing  uncommon.  What  is 
more  important,  there  rnay  be  defects  and  blemishes, 
which  strike  the  eye  of  a  stranger  very  forcibly,  that 
the  parent,  having  the  child  constantly  before  him,  is 
scarcely  sensible  of  their  existence.  My  object  is  the 
diffusion  of  medical  information,  in  the  hope  that  it 
may  prove  useful  to  others.  Could  the  reverse  be  sup- 
posed, or  that  any  one  part  of  the  work  might  lead 
to  unsound  conclusions,  or  incorrect  practice,  most 
sincerely  would  the  author  regret  that  any  of  his  ma- 
nuscripts ever  found  their  way  into  the  hands  of  the 
printer.  So  far,  then,  from  shrinking  from  criticism  in  the 
spirit  of  candour  and  kindness,  it  is  rather  invited,  never 
expecting  to  be  too  old  to  learn,  and  always  desiring  to 
have  my  errors  corrected,  and  improvements  placed  in 
their  stead. 

It  is  one  of  the  consolations  of  my  life,  to  look  around 
among  an  extensive  acquaintance  with  the  medical  pro- 
fession, some  of  them  older,  but  a  very  large  majority 
younger  than  myself,  and  to  feel  that  they  are  my  bre- 
thren. Although  we  may  honestly  differ  in  some  of  our 
medical  views,  yet  I  can  rejoice  in  extending  the  hand 
of  friendship  to  a  numerous  body  of  fellow  labourers  in 
a  profession  which  has  for  its  object  the  mitigation  of 
human  misery,  and  the  preservation  of  human  life.  It 
is  a  profession  which  is  high,  and  ought  to  be  dignified 
and  honourable;  but  neither  its  dignity,  nor  its  honour, 
can  depend  upon  high  sounding  titles,  nor  upon  name. 
It  must  be  bottomed  on  solid  attainments  in  medical 
science,  and  separated  from  merely  sordid  views.  That 


328  CONCLUSION. 

it  is  still  associated  with  many  of  the  imperfections, 
which  are  incident  to  humanity,  is  freely  confessed, 
while  it  may  not  be  arrogant  to  believe,  that  the  nume- 
rous streams  which  flow  forth  from  the  fountain  of 
medical  science,  are  still  extending  their  blessings  over 
the  land,  carrying  with  them  healing  virtue  and  conso- 
lation to  the  afflicted  and  destitute. 

There  is  now  rising  around  us  a  large  body  of  ta- 
lented and  enterprising  young  men,  who  have  most  in- 
dustriously engaged  in  the  arduous  and  responsible 
duties  of  medical  life.  I  view  with  deep  interest  their 
rising  usefulness,  and  heartily  wish  them  good  speed. 

To  the  elder  members  of  the  profession,  and  to  some 
in  an  especial  manner,  my  feelings  are  of  no  ordinary 
character.  As  the  circle  narrows,  our  attachments  in- 
crease. How  many  have  we  followed  to  the  grave. 
The  very  hands  that  were  so  frequently  stretched  forth 
to  parry  the  arrow  of  the  archer,  have  at  last  fallen 
powerless  from  his  wound.  Some  of  us  have  stood 
side  by  side  in  times  of  public  calamity,  sharing  a  com- 
mon danger,  while  some  of  our  brethren  have  fallen  in 
the  conflict.  The  pestilence  which  walketh  in  dark- 
ness, and  wasteth  at  noon  day,  we  have  seen  to  come 
up  into  the  windows,  and  to  cut  off  the  young  men  from 
our  streets.  We  still  remain — we  still  join  in  daily 
professional  intercourse,  and  with  entire  confidence 
in  each  other,  share  mutual  responsibility.  How  can 
it  be  other  then,  that  the  humble  hope  should  be  in- 
duljied,  that  when  we  also  shall  fall  before  the  arrow  of 
the  destroyer,  the  spirits  that  are  now  congenial,  shall 
still  be  permitted  to  mingle  together,  and  enter  upon  a 
more  exalted  sphere  of  existence,  where  hope  will  be 
lost  in  fruition. 

FINIS. 


EXPLANATION  OF  THE  PLATES. 


Plate  I. 

View  of  the  interior  of  the  lower  part  of  a  bladder, 
with  a  diseased  prostate  gland,  to  show  the  effect  of 
an  enlargement  of  the  third  lobe  of  that  gland. 

a,  a.  Section  of  the  parietes  of  the  lower  part  of  the 
bladder,  posteriorly. 

b,  i,  b,  b.  The  diseased  prostate  gland  greatly  de- 
veloped. 

c,  The  third  lobe  of  the  gland  enlarged  and  project- 
ing into  the  cervix  of  the  bladder,  where  it  overhangs 
the  internal  orifice  of  the  urethra,  like  a  valve. 

d,  The  membranous  portion  of  the  urethra. 

e,  e.  Part  of  a  catheter  introduced  through  the  ure- 
thra into  the  bladder,  lifting  up  the  third  lobe  of  the 
prostate  gland  in  its  passage. 

J\f.  The  vesical  extremities  of  the  ureters. 
g,  g.  The  seminal  ducts. 

Plate  IL 

Interior  view  of  the  bladder,  with  enormous  deve- 
lopcment  of  the  third  lobe  of  the  prostate  gland. 

a,  a.  Section  of  the  parietes  of  the  bladder. 

h,  b,  b.  Enlarged  prostate  gland. 

c.  Third  lobe  of  the  gland  projecting  far  into  the 
bladder. 

42 


330  EXPLANATION  OF  THE  PLATES. 


Plate  III. 

Section  and  interior  view  of  the  fundus  of  a  bladder 
taken  from  a  subject  with  enlarged  prostate  gland;  show- 
ing the  columns  of  the  mucous  coat,  caused  by  long- 
continued  dysuria,  and  resembling  the  muscular  columns 
of  the  heart. 

Plate  IV. 

Fig.  1.  A  canula  for  guiding  a  catheter  into  the 
bladder,  in  cases  of  enlarged  prostate  gland. 

«.  The  eye  of  the  instrument. 

b.  Two  marginal  notches  corresponding  exactly  with 
the  eye  of  the  instrument. 

Fig.  2.  The  extremity  of  the  same  instrument,  with 
the  catheter  introduced;  to  show  the  obliquity  of  the 
extremity  of  the  latter,  on  passing  out  at  the  eye. 

a.  The  end  of  the  catheter. 

Fig.  3.  A  view  of  Dr.  Parrish's  favourite  bistoury 
for  the  operation  on  strangulated  hernia. 


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